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Australian

Orthodontic Journal
Volume 23 Number 2, November 2007

Contents
Original articles
89 96 104 109 114 Cranial base and airway morphology in adult Malays with obstructive sleep apnoea Saeed M. Banabilh, A.H. Suzina, Sidek Dinsuhaimi and G.D. Singh Accuracy of bracket placement by orthodontists and inexperienced dental students David Armstrong, Gang Shen, Peter Petocz and M. Ali Darendeliler Fracture characteristics of fibre reinforced composite bars used to provide rigid orthodontic dental segments Soodeh Tahmasbi, Farzin Heravi and Saied Mostafa Moazzami Assessment of palatal bone thickness in adults with cone beam computerised tomography Antonio Gracco, Lombardo Luca, Mauro Cozzani and Giuseppe Siciliani Vertical changes in treated and untreated Class II division 1 malocclusions Craig Sharp, Michael Harkness and Peter Herbison The relationships between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature Jan van Gastel, Marc Quirynen, Wim Teughels and Carine Carels Treatment of a Class I deep bite malocclusion in a periodontally compromised adult Marcelo do Amaral Ferreira and Rogrio do Amaral Ferreira Use of miniscrews as temporary anchorage devices in orthodontic practice. II Case reports George Anka Molar distalisation with skeletal anchorage Antonio Gracco, Lombardo Luca and Giuseppe Siciliani What is a minimal clinically important difference? Michael Harkness Force and tooth movement Brian Lee Why would anyone be interested in measurement error? Peter Herbison When should we finish with a Class I molar relationship? Hussam M. Abdel-Kader Thomas Graber (1917-2007) Book reviews Interview Recent publications In appreciation New products Calendar Index
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Review
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Case reports
130 137 147

Editorial
153

Letter
155

Comment
156 157

Obituary
160 161 169 177 180 182 183 185

General

Cranial base and airway morphology in adult Malays with obstructive sleep apnoea
Saeed M. Banabilh, * A.H. Suzina, * Sidek Dinsuhaimi * and G.D. Singh
Department of ORL-HNS, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia* and Department of Speech and Hearing Sciences, Portland State University, Portland, USA

Background: Obstructive sleep apnoea (OSA) has been described as a public health problem comparable to smoking in its impacts upon society. Objective: To compare the differences in cranial base and airway morphology in Malay adults with and without OSA using finite element analysis (FEM). Method: Lateral skull radiographs of 38 adult Malays aged 1860 years were divided into two groups of 19 (13 male, 6 female). The first group consisted of 19 patients with OSA, defined as an apnoea-hypopnea index > 5/hr of sleep, diagnosed with overnight polysomnography. The second group consisted of 19 healthy, non-OSA control subjects. For each lateral skull radiograph 27 homologous landmarks, which encompassed the naso-oropharyngeal airway, were digitised using MorphoStudio software. The mean OSA and control 2D airway configurations were computed and subjected to t-tests and FEM. Results: The mean 2D OSA airway was statistically different from the mean control airway (p < 0.01). Inter-landmark analysis revealed that the cranial base saddle angle was more acute in the OSA group (153.9 degrees 3.4) compared to the control group (158.3 degrees 2.5; p < 0.01). In addition, using pseudo-coloured FEM a relative 58 per cent decrease in nasopharyngeal airway area was found above and behind the soft palate. As well, a 32 per cent decrease in oropharyngeal airway area was located behind the base of the tongue, with a 23 per cent decrease in hypopharyngeal area near the level of the hyoid bone. In contrast, a 96 per cent increase in area associated with downward displacement of the hyoid bone was detected. Conclusion: Functional airway impairments associated with OSA can be quantified and localised in Malay patients, and are predominantly associated with the morphology of the posterior regions of the cranial base. (Aust Orthod J 2007; 23: 8995)
Received for publication: March 2007 Accepted: May 2007

Introduction
Obstructive sleep apnoea (OSA) has come to the forefront in the last 30 years, and has been described as a public health problem comparable to smoking in its effects upon society.1 The Wisconsin Sleep Cohort study suggested that the prevalence of OSA among middle-aged women and men is 9 per cent and 24 per cent respectively (regardless of the presence of symptoms), while the prevalence of OSAS (OSA plus presence of excessive daytime sleepiness) is 2 per cent in women and 4 per cent in men.2 It is thought that the pathophysiology of OSA involves factors that relate to the anatomical dimensions of the upper airway, upper airway resistance and upper airway muscle activity during sleep.3 Therefore, upper airway
Australian Society of Orthodontists Inc. 2007

morphology is often measured in investigations of upper airway mechanics and OSA pathophysiology. The upper airway has been categorised into three anatomical regions: the nasopharynx (the area behind the nose and above the soft palate); the oropharynx (the area from soft palate to upper border of the epiglottis), which is subdivided into the retropalatal area (behind the palate) and the retroglossal area (behind the tongue); and the hypopharynx (laryngopharynx), which is the area from the upper border of epiglottis to the inferior border of the cricoid cartilage.4 Many techniques have been used to measure upper airway morphology, including nasopharyngoscopy,5 acoustic reflectance,6 computerised tomography7 and
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magnetic resonance imaging.8 Although all these techniques can be used to accurately measure upper airway morphology, the invasive nature of some of them is disadvantageous. As well, while most previous studies compared OSA airway morphology using conventional techniques,910 only a few studies have used robust geometric morphometric methods such as finite element morphometry (FEM). For example, FEM was used to model the upper airway and to create anatomically correct sagittal pharyngeal airways, as well as to assess the collapsibility of the upper airway.11 Similarly, pharyngeal cross-sectional areas were assessed using FEM.5 Recently, Singh et al.12 used FEM to quantify changes in the upper airway in children undergoing functional orthodontic treatments. Using FEM, change in morphology is viewed as a deformation of an initial geometric configuration, whose boundaries are formed by edges that connect anatomical landmarks into a final form.13 Indeed, this technique has been employed previously in a study of craniofacial growth,14 facial soft tissue changes1517 and dental arch features.18 It is thought that FEM allows a better understanding and visualisation of the magnitude and direction of morphologic change.19 Hence, this study was undertaken to determine whether any morphologic differences can be identified in the upper airway of adult Malays with and without OSA, using FEM. The aim of this study is to test the null hypothesis that no morphologic differences in terms of upper airway size and shape are identifiable in the two groups. Rejection of the null hypothesis might indicate how OSA might be better managed in patients of diverse ethnicity.

sleepiness scale was not used in this comparative, cross-sectional study. Exclusion criteria for sample selection were any subjects with psychiatric illness, sedative and/or alcohol intake, patient-specific disorders (such as neuromuscular disorders) and any craniofacial deformity, such as cleft lip and/or palate. An overnight hospital type III sleep study with PSG monitoring was performed on each subject between 2200 hours and 0600 hours. All variables were recorded simultaneously and continuously on a limited standard 8 channel PSG (Somnologica, lceland) at HUSM Sleep Science Laboratory. Occurrence of OSA was scored when there was cessation of breathing for >10 seconds or associated with evidence of persistent respiratory effort. Hypopnea was scored when there was >50 per cent decrease in the airflow signal with >3 per cent decrease in arterial oxygen saturation.20 Therefore, the severity of OSA was evaluated by the AHI, defined as the total number of apnoeas and hypopneas divided by the total sleep time in minutes. On the lateral skull radiographs, 27 homologous landmarks, which encompassed the upper airway, were digitised using MorphoStudio software to obtain the x, y coordinates (Figure 1). All data were subjected to duplicate digitisation by the same investigator (SMB) on two different occasions. Next, Procrustes superimposition was implemented to obtain a generalised rotational fit, that is, all configurations were scaled to an equivalent size and registered with respect to one another. Thus, mean 2D nasopharyngeal airway morphologies were determined for both groups, and FEM was used to compare the mean OSA airway with the mean control airway. For statistical testing, the Procrustes means were subjected to Students t-tests to identify elements showing significant changes. In addition, MorphoStudio software was used to perform an inter-landmark analysis to detect changes in length, and the statistical behaviour of the 2D linear distance between specific landmarks on the mandible (gonion) and the body of the hyoid bone in the Procrustes means. Finally, the cranial base saddle angle (nasion-sella-basion, N-S-PPW1) was also measured and subjected to Students t-tests. No other cephalometric parameters were utilised in this particular study, which was largely based on geometric morphometric techniques. To demonstrate sources of cranial base heterogeneity, FEM was undertaken that incorporated a spline

Materials and methods


This multidisciplinary study took place in the Department of Otorhinolaryngology, Hospital Universiti Sains Malaysia (HUSM). After obtaining appropriate consent, lateral skull radiographs were taken for a total of 38 adult Malays aged 1860 years. The first group consisted of 19 patients (13 males, 6 females) with OSA, defined as an Apnoea-Hypopnea Index (AHI) > 5/hr of sleep, diagnosed with limited overnight polysomnography (PSG). The second group consisted of 19 (13 males, 6 females) healthy, non-OSA control subjects who did not have any apnoeic symptoms as evaluated by the attending physician and limited channel PSG, but the Epworth

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1 0 4 2 5 6 7 10 9 3 25

13 15 17 19 21

14

11 16 12 18 20 23 22

24

26

Figure 1. Homologous landmarks employed for airway space evaluation. 0. Sella: centre of sella turcica. 1. Nasion. 2. Posterior cranial base: point directly below sella in the vertical plane that intersects with the inferior surface of the posterior cranial base. 3. Posterior nasal spine. 4. Superior pterygomaxillare: superior point where pterygoid process of sphenoid bone and pterygoid process of the maxilla form the pterygomaxillary fissure. 5. Inferior pterygomaxillare: lowest point of the opening of the pterygomaxillary fissure as defined above. 6. Atlas: anterior-most point on anterior process of the atlas. 7. Atlas soft: anterior-most point on posterior pharyngeal wall in the horizontal plane directly opposing atlas. 8. Uvula: most inferior point on the tip of the uvula. 9. Uvula dorsum: point of maximum convexity on the dorsum of the uvula. 10. Posterior pharyngeal wall 1 (PPW1): point directly opposing PNS in the horizontal plane on the posterior pharyngeal wall. 11. Gonion: lowest and most posterior point on the angle of the mandible. 12. Base of tongue: most posterior point on the posterior surface of the dorsum of the tongue. 13. Second cervical vertebra lower: lowest point of the C2 intervertebral disc. 14. Soft second cervical vertebra: point on the surface of the posterior pharyngeal wall in the horizontal plane directly opposite point 13. 15. Third cervical vertebra: highest point of the intervertebral disc of C3. 16. Soft third cervical vertebra: point on the surface of the posterior pharyngeal wall in the horizontal plane directly opposite point 15. 17. Third cervical vertebra lower: lowest point of the C3 intervertebral disc. 18. Soft third cervical vertebra lower: point on the surface of the posterior pharyngeal wall in the horizontal plane directly opposite point 17. 19. Fourth cervical vertebra: highest point of the intervertebral disc of C4. 20. Soft fourth cervical vertebra: point on the surface of the posterior pharyngeal wall in the horizontal plane directly opposite point 19. 21. Fourth cervical vertebra lower: lowest point of the intervertebral disc of C4. 22. Soft fourth cervical vertebra lower: point on the surface of the posterior pharyngeal wall in the horizontal plane directly opposite point 21. 23. Epiglottis: superior tip of epiglottis. 24. Hyoid: anterior-most point on body of hyoid bone. 25. Anterior nasal spine. 26. Gnathion: most antero-inferior point on mandibular profile.

interpolation function on a personal computer. FEM can be used to depict transformations in terms of allometry (size-related shape change) and anisotropy (directionality of shape change).21 Based on this approach, differences can be described graphically as a size-change, shape-change or both. Change in form between the reference configuration and the final configuration is viewed as a continuous deformation, which can be quantified based on major and minor strains (principal strains). If the two strains are equal, the form change is characterised by a simple increase or decrease in size, but if one of the principal strains changes in a greater proportion, transformation occurs in both size and shape. The product of the strains indicates a change in size if the result is not equal to 1. A product greater than 1 represents an increase in size equal to the remainder, for example, 1.30 indicates a 30 per cent increase. On the other hand, a result of 0.80 indicates a 20 per cent decrease in size. Changes in shape are determined by the ratio of the principal extensions, where a value not equal to 1 represents an observable change in shape. The products and ratios can be resolved for individual landmarks within the configuration, and these can be linearised using a log-linear scale and pseudo-colour coded to provide a graphic display of size- and shapechange.

Results
The control group included subjects whose AHI ranged from 04.20 For the OSA group, patients with mild OSA presented with an AHI of 515. Patients with moderate OSA demonstrated an AHI of 1530. Patients with severe OSA had an AHI >30. In this study, 6 patients had mild OSA, 4 had moderate OSA and 9 had severe OSA. The mean AHI for the OSA group was 37.6 24.3 per hour while the mean AHI for the control group was 1.6 2.1 per hour (p < 0.001). The mean oxygen saturation of the OSA group was 94.2 per cent 3.8 while the mean oxygen saturation for the control group was 98 per cent 0.9 per hour (p < 0.001). The mean BMI for the control group was 20.5 2.6 and the BMI for the OSA group was 33.8 7.4 (p < 0.001). On duplicate digitisation of the landmarks, no significant differences were found (p > 0.05) using a method equivalent to Dahlbergs formula, and therefore the study digitisation error was assumed to have no effect on the findings. The inter-landmark

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Figure 2. Comparison of mean OSA and normal airway configurations for size change. Overall the airway space is narrower in the posterior region for the OSA group. Using the entire vertical pseudo-colour scale bar, which indicates the degree of size-change, a relative 58 per cent decrease in nasopharyngeal airway area is found above and behind the soft palate indicated by the light and dark blue pseudo-colouration.

Figure 3. Comparison of mean OSA and normal airway configurations for directionality of change. The circular pseudo-colour scale indicates direction. The two green areas indicate narrowing of the airway in the antero-posterior plane. The blue central zone indicates a 45 degrees axis of antero-posterior narrowing, while the purple regions indicate vertical.

analysis on the Procrustes means revealed that the linear distance from gonion (angle of the mandible) to the body of the hyoid bone increased in length by approximately 47 per cent (p < 0.01) for the OSA group, and the cranial base saddle angle was more acute in the OSA group (153.9 degrees 3.4) compared to the control group (158.3 degrees 2.5; p < 0.01). In addition, the results of the t-tests indicated that the normalised mean OSA airway was statistically different from the mean control airway (p < 0.01). Comparison of the nasopharyngeal region indicated that striking changes were detected using FEM, as the OSA configurations showed a relative 5878 per cent decrease in area in the posterior cranial base and nasopharyngeal region above and behind the soft palate (Figure 2, vertical pseudo-colour scale). Specifically, the posterior pharyngeal wall (PPW1) was involved in the reduction in area. However, localised increases in area of 3055 per cent were found further anteriorly (Figure 2). In addition, shapechanges were highly anisotropic (non-uniform). The directionality of these non-homogeneous shape changes is shown in Figure 3, which indicates a 45 degrees axis of narrowing with respect to the midsagittal plane (blue colour using the circular pseudo-colour scale). As well, antero-posterior narrowing is indicated by the green region visible in Figure 3 (using the circular colour scale).

Comparison of the oropharyngeal region indicated a 2830 per cent increase in area posteriorly, allied with a 3245 per cent decrease in oropharyngeal airway area located behind the base of the tongue (Figure 2, vertical pseudo-colour scale). In addition, shapechanges were highly anisotropic. The directionality of the shape changes identifies antero-posterior narrowing, as indicated by the green region using the circular pseudo-colour scale (Figure 3). Comparison of hypopharyngeal region indicated a 23 per cent decrease in hypopharyngeal area near the level of the fourth cervical vertebra, C4 (blue colour, Figure 2, vertical pseudo-colour scale). Moreover, the hyoid bone moved more inferiorly with respect to the angle of the mandible (gonion), and C4 appeared to locate posteriorly. Accordingly, a 7096 per cent increase in area was noted in the submandibular region associated with downward displacement of the hyoid bone. In addition, shape-changes were highly anisotropic. The directionality of the shape changes identifies supero-inferior elongation as indicated by the purple coloration but, antero-inferior (blue) and postero-inferior (red) deformations are also demonstrable in that region, using the circular pseudo-colour scale (Figure 3).

Discussion
In this study, the characteristics of the cranial base and upper airway morphology in Malay patients with

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obstructive sleep apnoea (OSA) were investigated using finite element analysis (FEM). While most previous studies compared OSA cranial base and airway morphology using conventional techniques,910 only a few studies5,1112 have used FEM, a relatively new analytic tool. Although the FEM method appears to be somewhat theoretical, one advantage is that the results are presented graphically and one can view changes in size or shape. Nevertheless, the current study could not overcome some methodological limitations. For example, the radiographs employed for the study were obtained during wakefulness. However, there have been clearly documented abnormalities of upper airway anatomy and physiology in subjects with OSA during wakefulness. Therefore, we believe that careful anatomic/physiologic assessment during wakefulness may provide some valuable information even though cephalometric data cannot escape the limitations of 2D imaging. In this study the mean cranial base configuration of the OSA group was compared to that of a nonapnoeic control group. For the groups studied, the inter-landmark analysis on the Procrustes means revealed that patients with OSA had a significantly more acute cranial base flexure angle (153.9 degrees 3.4) when compared to the control group (158.3 degrees 2.5). In addition, relative 5878 per cent decreases in area of the posterior cranial base region were found using FEM (Figure 2). These findings support the view that an acute cranial base flexure angle may be responsible for a decrease in pharyngeal airway dimension in patients with OSA by reducing the distance between the anterior and the posterior pharyngeal walls, and bringing the cervical spine and posterior pharyngeal wall further forwards.22 Both of these mechanisms would potentially reduce the space available for the airway.9 Indeed, the presence of a narrower than normal pharyngeal diameter in OSA patients has been previously documented using conventional techniques. For example, in Japanese patients with OSA all upper airway cephalometric variables were smaller compared with a control group.23 In addition, the majority of CT and MRI studies indicate that even during wakefulness the upper airway of patients with OSA is smaller than controls.24 Our results localise the anatomical regions of the upper airway affected and quantify the decrease in airway area in the OSA group compared with a

matched, non-apnoeic, control group using a FEM technique. In a previous study, the antero-posterior width of the bony nasopharynx and oropharynx were also significantly reduced in obese and non-obese patients with OSA.25 The smaller width of the bony pharynx may reflect a posterior position of the maxilla secondary to cranial base morphology, and together with an enlarged soft palate may contribute to upper airway narrowing. In addition, narrowing of the oropharynx as shown in this present study may displace the tongue into the hypopharyngeal space, and that displacement may play an important role in the development of OSA (Figures 2 and 3). Another finding of our study is that the hyoid bone was displaced more inferiorly with respect to the angle of the mandible (gonion), and the fourth cervical vertebra (C4) appeared to relocate posteriorly. Accordingly, a 7096 per cent increase in area was noted in the submandibular region. This displacement occurred in the vertical plane predominantly (Figure 3). Many previous studies have shown that patients with OSA have inferior displacement of the hyoid bone,2,10, 2527 which is found lower at the level of cervical vertebrae C4-C6 compared to controls, in whom it is typically located at the level of C3-C4. Indeed, it has been suggested that a large neck circumference is caused not only by obesity or fat deposition, but also by inferior positioning of the hyoid bone allied with posterior positioning of C4.28 It has also been suggested that an inferiorly placed hyoid bone relocates the tongue base into the hypopharynx, and thus the patency of the hypopharyngeal airway is adversely affected.29 These ideas might also explain the case in Malay patients with OSA. The lower position of the hyoid bone in this group of patients might be a compensatory mechanism to ease the increased airway resistance caused by reduced airway space.30 Alternatively, in Asian patients with OSA other morphological abnormalities such as a large cranial base might be a major contributor to the pathogenesis of OSA.31 Indeed, habitual snorers show a significant decrease in sagittal cranial base dimensions32 and for patients with OSA, craniofacial abnormalities include a greater flexion of the cranial base.33 Similarly, compared with normal subjects, Chinese patients with OSA exhibit a shortened cranial base.34 In Chinese-Singaporeans, a narrower skull base has also been reported.35 In Chinese males with severe
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OSA craniocervical extension was significantly increased, while differences were also found for anterior cranial base length.36 In terms of effect, Wong et al.28 suggest that craniocervical angulation and head posture correlate with airway resistance associated with OSA in Malaysian patients. Robertson37 also reported that while nearly all linear cranial base dimensions are smaller in patients with OSA, these failed to reach statistical significance, presumably due to the lack of normalisation in that study. Ono et al.38 reported that when patients with OSA changed their posture from upright to supine, significant correlations were observed between the cranial base and upper cervical column angle. Tangugsorn et al.39 also reported a shorter cranial base dimension with counterclockwise rotation and depression of the clivus in patients with OSA. Therefore, on the basis of the current results, we also conclude that an acute cranial base flexure angle is one important craniofacial factor, which may be responsible for OSA in Malays. Consequently, examination and evaluation of the cranial base and upper airway anatomy must be undertaken to confirm the diagnosis of OSA and support decision-making among various treatments. As the use of mandibular advancement devices would be contraindicated in patients presenting with Class III malocclusions secondary to cranial base morphology,4041 we suggest that changing the size of the apnoeic airway could be achieved by non-surgical alterations of structures that surround the upper airway. This notion is currently under investigation and remains as the premise for future studies.

References
1. 2. Phillipson EA. Sleep apnoea a major public health problem. N Engl J Med 1993; 328:12713. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:12305. Hudgel DW. The role of upper airway anatomy and physiology in obstructive sleep apnoea. Clin Chest Med 1992;13: 38398. Rama AN, Tekwani SH, Kushida CA. Sites of obstruction in obstructive sleep apnoea. Chest 2002;122:113947. Mansour KF, Rowley JA, Badr MS. Measurement of pharyngeal cross-sectional area by finite element analysis. J Appl Physiol 2006;100:294303. Mohsenin V. Effects of gender on upper airway collapsibility and severity of obstructive sleep apnoea. Sleep Med 2003;4: 5239. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis 1993;148:1385400. Welch KC, Foster GD, Ritter CT, Wadden TA, Arens R, Maislin G et al. A novel volumetric magnetic resonance imaging paradigm to study upper airway anatomy. Sleep 2002;25:53242. Battagel JM, Johal A, Kotecha B. A cephalometric comparison of subjects with snoring and obstructive sleep apnoea. Eur J Orthod 2000;22:35365. Hou HM, Sam K, Hagg U, Rabie AB, Bendeus M, Yam LY et al. Long-term dentofacial changes in Chinese obstructive sleep apnoea patients after treatment with a mandibular advancement device. Angle Orthod 2006;76:43240. Malhotra A, Huang Y, Fogel RB, Pillar G, Edwards JK, Kikinis R et al. The male predisposition to pharyngeal collapse: importance of airway length. Am J Respir Crit Care Med 2002;166:138895. Singh GD, Garca-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morphometrics. Cranio 2007;25: 8489. Singh GD, McNamara JA Jr., Lozanoff S. Morphometry of the cranial base in subjects with Class III malocclusion. J Dent Res 1997;76:694703. Singh GD, Rivera-Robles J, de Jesus-Vinas J. Longitudinal craniofacial growth patterns in patients with orofacial clefts: geometric morphometrics. Cleft Palate Craniofac J 2004;41: 13643. Singh GD, Maldonado L, Thind BS. Changes in the soft tissue facial profile following orthodontic extractions: a geometric morphometric study. Funct Orthod 2004;22: 348, 40. Singh GD, McNamara JA Jr., Lozanoff S. Finite-element morphometry of soft tissues in prepubertal Korean and European-Americans with Class III malocclusions. Arch Oral Biol 1999;44:42936. Banabilh SM, Rajion ZA, Samsudin AR, Singh GD. Facial soft tissue features assessed with finite element analysis. Int J Orthod Milwaukee. 2006;17:1720. Banabilh SM, Rajion ZA, Samsudin R, Singh GD. Dental arch shape and size in Malay schoolchildren with Class II malocclusion. Aust Orthod J 2006;22:99103. McAlarney ME, Chiu WK. Comparison of numeric techniques in the analysis of cleft palate dental arch form change. Cleft Palate Craniofac J 1997;34:28191. The report of an American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults:

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Acknowledgment
This study was funded by a short term research grant (No. 304/PPSP/6131489) from Universiti Sains Malaysia.
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Corresponding author
Professor G.D. Singh Department of Speech and Hearing Sciences Portland State University 85 Neuberger Hall 724 SW Harrison St Portland, OR 97207-0751 USA Fax: (+1) 866 201 3869 Email: gdsingh27@gmail.com
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32. Zucconi M, Ferini-Strambi L, Palazzi S, Curci C, Cucchi E, Smirne S. Craniofacial cephalometric evaluation in habitual snorers with and without obstructive sleep apnoea. Otolaryngol Head Neck Surg 1993;109:100713. 33. Cistulli PA. Craniofacial abnormalities in obstructive sleep apnoea: implications for treatment. Respirology 1996;1: 16774. 34. Tong M, Xia X, Cao E. Cephalometric analysis of the craniofacial bony structures in patients with obstructive sleep apnoea. Zhonghua Jie He He Hu Xi Za Zhi 1999;22: 3357. [Article in Chinese] 35. Hsu PP, Tan AK, Chan YH, Lu PK, Blair RL. Clinical predictors in obstructive sleep apnoea patients with calibrated cephalometric analysis a new approach. Clin Otolaryngol 2005; 30:23441. 36. Hou HM, Hagg U, Sam K, Rabie AB, Wong RW, Lam B, Ip MS. Dentofacial characteristics of Chinese obstructive sleep apnoea patients in relation to obesity and severity. Angle Orthod 2006;76:9629. 37. Robertson C. Cranial base considerations between apnoeics and non-apnoeic snorers, and associated effects of long-term mandibular advancement on condylar and natural head position. Eur J Orthod 2002;24:35361. 38. Ono T, Lowe AA, Ferguson KA, Fleetham JA. Associations among upper airway structure, body position, and obesity in skeletal Class I male patients with obstructive sleep apnoea. Am J Orthod Dentofacial Orthop 1996;109:62534. 39. Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod 1995;17:4556. 40. Singh GD, McNamara JA, Lozanoff S. Allometry of the cranial base in prepubertal Korean subjects with class III malocclusions: finite element morphometry. Angle Orthod 1999;69:50714. 41. Singh GD, McNamara JA, Lozanoff S. Craniofacial heterogeneity of prepubertal Korean and European-American subjects with Class III malocclusions: Procrustes, EDMA, and cephalometric analyses. Int J Adult Orthodon Orthognath Surg 1998;13:22740.

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Accuracy of bracket placement by orthodontists and inexperienced dental students


David Armstrong, * Gang Shen, * Peter Petocz and M. Ali Darendeliler *
Department of Orthodontics, Faculty of Dentistry, Sydney Dental Hospital, The University of Sydney, Sydney, Australia* and Department of Statistics, Macquarie University, Sydney, Australia

Background: Well-finished orthodontic treatment begins with accurate positioning of the brackets on the teeth. Aims: To compare the positions of orthodontic brackets placed by experienced clinicians and inexperienced trainees. Methods: Twenty orthodontists (13 male, 7 female) representing experienced specialists, and 20 final year dental students (10 male, 10 female) representing inexperienced trainees, were asked to bond pre-adjusted straight-wire brackets at the centres of the clinical crowns of the teeth in a Class I crowded typodont set-up. The teeth were removed from the typodont, placed in a standardised jig and photographed. The vertical, mesio-distal and angular (tip) positions of the brackets, relative to the centres of the clinical crowns, were measured with the aid of imaging software. The accuracy of bracket placement by the groups was compared. Results: The dental students took significantly longer than orthodontists to place the brackets (50.65 16.33 minutes vs 28.53 9.51 minutes, p < 0.001), but were more accurate than the orthodontists at positioning the brackets vertically (0.90 0.21 mm vs 1.19 0.23 mm, p < 0.001). There were no statistically significant differences between the dental students and the specialists in either the mesio-distal or the angular/tip positions of the brackets (p > 0.05). Both groups tended to bond the brackets with a distal tip. The students had slightly more right-left differences than the orthodontists. Mesio-distal errors in bracket placement were associated with rotated and displaced teeth. Conclusions: Accurate direct bonding of orthodontic brackets to teeth does not appear to be related to clinical experience or specialist training. (Aust Orthod J 2007; 23: 96103)
Received for publication: December 2006 Accepted: July 2007

Introduction
The developments of direct bonding and pre-adjusted appliances have allowed orthodontists to achieve good results with greater clinical efficiency. However, ideal bracket placement is often impossible due to the position of the teeth and operator error.1 Poorly positioned brackets result in poorly positioned teeth, which can lead to multiple rebonding of brackets, longer treatment and/or a less than ideal final occlusion.2 Indirect bonding has been advocated because it is more efficient, reduces chair time, maximises the use of assistants and is more accurate than direct bonding.3,4 Indirect bonding is more accurate than direct bonding for angular positioning of brackets on maxillary and mandibular canines and vertical positioning of brackets on the maxillary canines, but it is less
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accurate than direct bonding of brackets on the mandibular second premolars (p < 0.01).5 Koo et al. confirmed that indirect bonding was more accurate than direct bonding with respect to the vertical dimension, but there were no statistically significant differences between direct and indirect bonding in either the angulation or the mesio-distal positions of the brackets.6 Recently, it has been reported that in both methods, the mean bracket placement errors were similar.7 Taylor and Cook8 looked at direct bracket placement on the anterior teeth in a typodont set-up, and found that angular judgements by the participants were less consistent than linear assessments. They reported that no participant was able to reposition a bracket in the same position: some participants could reposition brackets within a 2 degree limit, but others had a variability of 19 degrees. This questions whether the
Australian Society of Orthodontists Inc. 2007

ACCURACY OF BRACKET PLACEMENT

Figure 1. The simulated Class I malocclusion.

variation is due to experience or to natural ability.8 Balut and coworkers9 looked at the accuracy of 10 faculty members bonding brackets to teeth in five typodont set-ups. They reported means of 0.34 0.29 mm for vertical discrepancies and 5.54 4.32 degrees for angular discrepancies. Three faculty members had significant angular deviations and two faculty members had significant vertical deviations. These findings suggest that different operators have different abilities at placing brackets. Fowler10 reported that training and experience reduced both the intra- and inter-clinician error, however the reductions were small. He also reported that more recently trained clinicians were more consistent and more accurate in identifying the long axes of clinical crowns than experienced clinicians. It is uncertain whether the accuracy of bracket placement is related to clinical experience, recent training, natural ability or diligence.1113 This study was designed to compare the abilities of experienced clinicians and inexperienced dental students to bond orthodontic brackets in the centres of the clinical crowns of the teeth in a standardised typodont set-up. All participants were given the same set of instructions, and a typodont set-up was used to simulate the clinical situation and avoid some of the variables associated with patients.

Figure 2. The typodont with synthetic latex lips preventing direct vision of the premolar teeth.

positioning orthodontic brackets. All participants were right handed.

Typodont set-up
Forty typodonts were set-up with the same Class I, crowded malocclusion. No tooth was so severely displaced that it prevented a bracket from being placed in the centre of the clinical crown (Figure 1). The typodont was then mounted on an adjustable rod to allow each operator to position the typodont as they would position a patients head during bonding. Synthetic latex lips were used to prevent direct vision of the premolar teeth (Figure 2). All participants were given a prepared handout with photographs illustrating the position each bracket was to be placed, and a selection of instruments (mirror, probe, periodontal probe, scaler, Hollenbach, flat plastic, rule and Unitek height gauge). They were also asked if they required any further instruments. Prior to the placement of the brackets the teeth were sandblasted with 50 mm alumina particles for 10 seconds. A cheek retractor (Sasa, Kongivor, Norway) was then placed, and the participants were asked to bond 20 Victory series low profile MBT brackets (3M Unitek, Monrovia, CA, USA) on the typodont teeth using Transbond (3M Unitek, Monrovia, CA, USA), and remove any excess adhesive. The brackets were then cured with the curing light available in each surgery. The time taken to complete the bonding was recorded. As the bond strengths of the brackets were not tested standardisation of the curing light was not necessary.
Australian Orthodontic Journal Volume 23 No. 2 November 2007

Materials and methods Participants


The participants represented two groups with different levels of clinical experience and knowledge of orthodontics: group 1 consisted of 20 orthodontists (13 male, 7 female) representing the experienced clinicians, and group 2 was composed of 20 final year dental students (10 male, 10 female) representing the dental trainees with no previous experience at

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Figure 3. The photographic set-up used to record bracket placement on each tooth. A print of an upper central incisor is indicated by the arrow.

Figure 4b. Mesio-distal positioning error. The difference between the mesiodistal midpoints of the bracket (dark line) and the clinical crown (light line). The outer lines indicate the mesial and distal surfaces.

Figure 4a. Vertical positioning error. The difference between the centre of the bracket (dark line) and the incisal edge and the centre of the clinical crown and the incisal edge (light line).

Figure 4c. Angular (tip) positioning error. The angle between the long axis of the bracket (dark line) and the long axis of the clinical crown (light line).

Identifying the bracket placement deviation or error


The teeth were removed from the typodont and the excess wax removed. Each tooth was then placed in an individually made jig (Odontosil, DreveDentamid GMBH, Germany) and two digital photographs were taken (buccal and occlusal) using a Nikon D1 fitted with a Nikon 110 lens (Figure 3). The digital images were opened using AnalysSIS Pro 3.1 (Soft imaging system, Munich, Germany) and
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magnified to the same scale using the rule attached to the jig. The vertical position, the mesio-distal position and the angulation of the brackets were measured three times, and the mean of the three measurements used in all subsequent calculations. The positioning errors were: 1. Vertical positioning error. Two diagonal lines were drawn across the archwire slot to locate the centre of the slot. The vertical height of the bracket was then measured from the incisal edge to the intersection

ACCURACY OF BRACKET PLACEMENT

Table I. Errors in bracket placement by orthodontists and dental students.

Teeth* Mean

15 SD Mean

14 SD Mean

13 SD Mean

12 SD Mean

11 SD

Vertical Mesio-distal Tip

Orthod Student Orthod Student Orthod Student


Teeth

1.31 1.18 0.10 0.11 -2.13 -4.84


21 Mean

0.31 0.39 0.15 0.30 4.28 3.92


SD

0.66 0.37 -0.15 -0.16 -4.57 -6.42


22 Mean

0.44 0.36 0.18 0.22 4.74 4.46


SD

1.34 0.63 -0.12 0.09 -2.04 -5.87


23 Mean

0.55 0.55 0.22 0.36 4.24 3.86


SD

1.26 0.77 -0.24 -0.25 1.32 -0.83


24 Mean

0.36 0.34 0.12 0.16 1.62 3.75


SD

2.24 1.70 -0.11 -0.14 -2.26 -1.66


25 Mean

0.44 0.27 0.24 0.24 3.91 2.73


SD

Vertical Mesio-distal Tip

Orthod Student Orthod Student Orthod Student


Teeth

2.08 1.31 -0.13 -0.03 -0.45 0.69


45 Mean

0.36 0.37 0.26 0.19 2.76 2.371


SD

1.47 1.02 -0.02 -0.15 1.52 2.55


44 Mean

0.29 0.39 0.20 0.15 2.95 2.39


SD

1.68 1.00 -0.02 -0.01 -2.22 0.23


43 Mean

0.59 0.52 0.29 0.377 5.395 4.692


SD

0.77 0.38 -0.12 0.04 -1.17 -4.00


42 Mean

0.41 0.37 0.25 0.35 4.89 5.96


SD

0.89 0.86 -0.23 -0.47 -3.34 -2.78


41 Mean

0.26 0.38 0.29 0.35 4.49 3.50


SD

Vertical Mesio-distal Tip

Orthod Student Orthod Student Orthod Student


Teeth

0.77 0.98 -0.06 -0.38 -0.27 0.66


31 Mean

0.54 0.49 0.43 0.22 6.24 3.50


SD

0.70 0.71 -0.26 0.14 0.33 -1.00


32 Mean

0.58 0.48 0.33 0.57 3.92 4.61


SD

1.19 0.65 -0.02 0.22 -2.03 0.82


33 Mean

0.33 0.51 0.21 0.33 3.41 3.74


SD

1.28 1.07 -0.04 -0.05 -4.62 -2.27


34 Mean

0.33 0.32 0.13 0.17 2.80 2.50


SD

1.02 0.93 -0.23 -0.05 -0.49 0.48


35 Mean

0.34 0.27 0.16 0.15 1.99 2.26


SD

Vertical Mesio-distal Tip

Orthod Student Orthod Student Orthod Student

1.23 0.87 0.03 -0.11 -1.49 -1.94

0.37 0.37 0.16 0.18 2.85 2.14

1.34 1.05 -0.02 -0.29 -2.10 -0.25

0.39 0.41 0.14 0.20 3.55 2.46

1.27 0.87 -0.14 -0.07 -3.00 -2.57

0.39 0.32 0.28 0.29 3.49 3.04

0.57 0.72 -0.18 -0.33 -4.20 -2.74

0.50 0.48 0.34 0.48 3.82 4.39

0.83 0.90 0.15 0.06 1.60 0.93

0.47 0.53 0.41 0.63 5.36 5.70

* FDI notation Vertical and mesio-distal deviations in mm, tip/angular deviations in degrees

of the lines (Figure 4a). The vertical positioning error was calculated by subtracting this measurement from the actual centre of the clinical crown (length of the clinical crown/2).14 Positive values indicated displacement towards the incisal edge and negative values displacement towards the gingival margin. 2. Mesio-distal positioning error. This was measured from the occlusal image. The midpoint of the tooth was identified, and the horizontal distance from the midpoint of the tooth to the midpoint of the bracket

measured (Figure 4b). Deviations from the midline were given the following sign: positive (mesial) and negative (distal). 3. Angular/tip positioning error. This was defined as the angle between the vertical scribe line on the bracket and the long axis of the clinical crown. The two lines were highlighted and the software calculated the intersecting angle (Figure 4c). If the bracket was tipped mesially the value was recorded as positive, and if it was tipped distally a negative value was recorded.
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Table II. Comparison of the errors in bracket placement by orthodontists and students, significant findings only.

Deviation/Tooth Mean

Orthodontists SD Mean

Students SD

More accurate

Vertical 13 Tip 13 Vertical 12 Vertical 11 Vertical 21 Vertical 22 Vertical 23 Vertical 24 Mesio-distal 45 Vertical 43 Tip 42 Mesio-distal 41 Vertical 31 Mesio-distal 32 Vertical 33

1.34 -2.04 1.26 2.24 2.07 1.47 1.67 0.77 -0.06 1.19 -4.62 -0.23 1.23 -0.02 1.27

0.55 4.23 0.36 0.44 0.36 0.29 0.59 0.41 0.43 0.33 2.80 0.16 0.37 0.14 0.39

0.63 -5.87 0.77 1.70 1.31 1.02 1.00 0.38 -0.37 0.65 -2.27 -0.05 0.87 -0.29 0.87

0.55 3.86 0.34 0.27 0.37 0.39 0.52 0.37 0.22 0.51 2.50 0.15 0.37 0.20 0.31

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.003 <0.005 <0.001 0.008 0.001 <0.004 <0.001 0.001

Student Orthod Student Student Student Student Student Student Orthod Student Student Student Student Orthod Student

Vertical and mesio-distal deviations in mm, tip/angular deviations in degrees

Data statistics
The accuracy of the bracket placement was analysed using the Statistical Package for the Social Sciences (SPSS for Windows, Release 12.0, SPSSInc, Chicago, Illinois). Since multiple and related tests were performed, a significance level of p = 0.01 was used in all tests. The measurement error was calculated by remeasuring the brackets in one quadrant (the lower right) for three participants. The method error was determined using the coefficient of variation (CV), which is the standard deviation divided by the mean expressed as a percentage.15 It revealed that there was no significant difference between repeated measurements.

The means and standard deviations of the three measurements (vertical, mesio-distal and tip) for each tooth are given in Table I, and the significant findings in Table II. The majority of the tip errors were negative, which suggests that the participants tended to bond the brackets with a distal tip (Table I). This tendency was not statistically significant. Brackets bonded by the orthodontists were placed more incisally than the brackets bonded by the dental students (All, i.e. both upper and lower teeth: Orthodontists 1.19 0.23 mm; Dental students 0.90 0.21 mm, p < 0.001; Upper arch: Orthodontists 1.37 0.27 mm; Dental students 0.92 0.26 mm, p < 0.001). The vertical errors were then assessed relative to their mean bracket position vertically, and the dental students were slightly more accurate overall (Orthodontists: 0.56 0.11; Dental students: 0.46 0.07 mm, p = 0.001). There were no statistically significant differences between the groups when the mesio-distal and tip errors were compared (Table III). When the side-to-side differences in placement were determined the orthodontists had significant (p < 0.01) right-left differences for the following teeth: Vertical and mesio-distal errors: Teeth 15, 25; 12, 22; Vertical error: Teeth 13, 23; Mesio-distal error: Teeth 41, 31; Tip error: Teeth 44, 34. The dental students

Results
The mean age of the orthodontists was 41 years (SD: 7.61 years; Range: 2953 years), with on average of 8.88 years of experience (SD: 7.36 years; Range: 125 years). The mean age of the students was 26.4 years (SD: 4.08 years, Range: 2342 years). The time taken by the orthodontists to bond the 20 brackets was significantly shorter (Mean: 28.53 minutes; SD: 9.51; p < 0.001) than the time taken by the dental students (Mean: 50.65 minutes; SD: 16.33).
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ACCURACY OF BRACKET PLACEMENT

Table III. The difference in error of bracket placement between the upper and lower dental arches.

Orthodontists Mean SD Mean

Students SD p

Vertical

All Upper Lower All Upper Lower All Upper Lower All Upper Lower

1.19 1.37 1.02 0.56 0.60 0.44 -0.09 -0.11 -0.08 -1.61 -1.59 -1.63

0.23 0.27 0.24 0.11 0.13 0.15 0.06 0.06 0.11 1.02 1.41 1.25

0.90 0.92 0.87 0.46 0.51 0.37 -0.09 -0.10 -0.08 -1.54 -2.30 -0.79

0.21 0.26 0.26 0.07 0.10 0.07 0.09 0.07 0.14 1.25 1.84 1.40

0.000 0.000 0.075 0.001 0.024 0.053 0.983 0.707 0.833 0.857 0.180 0.054

Vertical relative to the mean

Mesio-distal

Tip

Paired t - test, significant values in bold Vertical and mesio-distal deviations in mm, tip/angular deviations in degrees

Table IV. Comparison of the mesiodistal errors in bracket placement with

the initial tooth position (+ mesial, - distal). Tooth Mesio-distal Mean SD Initial position Error

15 12 11 22 43 41 32 35

0.10 -0.25 -0.12 -0.08 0.10 -0.14 -0.15 0.11

0.23 0.14 0.24 0.18 0.30 0.17 0.22 0.53

Distal rotation Palatal Mesio-palatal rotation Palatal Distal rotation Lingual Mesio-lingual rotation Distal rotation

Mesial Distal Distal Distal Mesial Distal Distal Mesial

had more significant right-left differences than the orthodontists (p < 0.01): Vertical and mesio-distal errors: Teeth 15, 25; Vertical and tip errors: Teeth 13, 23; 12, 22; 11, 21; Tip error: Teeth 41, 31; Mesiodistal and tip errors: Teeth 42, 32; 4333; Mesiodistal error: Teeth 45, 35 (Table II). The teeth with the greatest malpositions were assessed and there was a trend for tooth position to be associated with specific mesio-distal errors in placement of the brackets (Table IV).

clinical orthodontics, to bond brackets to the centres of the clinical crowns of teeth in a standardised typodont set-up. The groups were experienced specialists and undergraduate dental students, and both groups were given the same instructions at the start. The accuracy of each participant to bond brackets in centres of the clinical crowns was assessed by measuring the deviations of the bonded brackets from the defined positions given to each participant. Not surprisingly, the orthodontists completed the exercise in slightly more than half the time taken by the students, with fewer side-to-side errors, but with a small, but statistically significant, difference in vertical positioning. The orthodontists placed the brackets more incisally than the students, although the latter also placed the brackets more incisally than requested. Although there was a tendency for the position of a tooth to predispose towards certain errors in placement, for example, brackets on mesiolingually rotated teeth tended to be placed more distally, the errors in placement were small and, it could be argued, may not be of clinical significance. Many orthodontists will agree that the pre-adjusted orthodontic appliances are an efficient and effective means of treating most malocclusions. Patient response to treatment can be an important limiting factor as well as the orthodontists ability to precisely place an appliance.16 Identification of bracket positioning errors is important, as poorly placed brackets may result in more archwire adjustments,
Australian Orthodontic Journal Volume 23 No. 2 November 2007

Discussion
This study was designed to compare the ability of two groups, each with a different experience of

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replacement of incorrectly placed brackets and increased treatment time.2 Although the finishing stage of treatment invariably requires the archwires to be modified because appliance prescriptions are based on averages, accurate placement of brackets at the start of treatment is considered to be an important step towards successful treatment.17 It was not surprising to find that the orthodontists needed less time to bond the 20 brackets than the dental students. With their greater experience of, and familiarity with, the materials one would expect them to perform the task more quickly and efficiently than the students. There was no time limit imposed on the participants, so the inexperienced students had ample time to complete the task. On average, the upper central incisor brackets bonded by the orthodontists were placed about 0.5 mm more incisally than the brackets bonded to the same teeth by the students. Other brackets had greater or lesser errors in placement. These findings may not be randomly distributed, but may be due to one or more of the following factors: the students followed the instructions more carefully than the orthodontists; the students were better than the orthodontists at identifying the centres of the clinical crowns; the orthodontists may have subconsciously placed the brackets more incisally because this is a common procedure in practice. All participants were asked to follow the instructions on the handout and not to modify the positions of the brackets to compensate for specific aspects of the malocclusion. Both groups bonded the brackets more incisally than requested. This is in agreement with Koo et al.6 who reported that directly placed brackets tended to be placed towards the incisal edge, but in contrast to others7 who found that directly placed brackets tended to be towards the gingival margins (0.27 0.46 mm). The vertical errors in this study (Orthodontists: 1.19 0.23 mm; Dental students: 0.9 0.21 mm) appear to be greater than the errors reported by other investigators (Table III). Other researchers8 studied the accuracy of bracket placements within or beyond a 0.5 mm range, and reported that more brackets fell within the range than outside it, which suggests that brackets can be accurately positioned vertically. In the present study the vertical errors relative to their means (Orthodontists: 0.56 0.11 mm; Dental students: 0.46 0.07 mm) are similar to those obtained by Balut et al. (0.34 0.29 mm).9
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Typodonts are frequently used for training in fixed appliance technique, but they are unable to exactly recreate the clinical situation. In particular, the teeth we used lacked a clearly demarcated cemento-enamel junction, which may have contributed to the vertical errors.18 All teeth were set up fully erupted so that the participants did not have to estimate the position of the cemento-enamel junction. There were no statistically significant differences between the orthodontists and dental students in relation to the mesio-distal or tip errors (Table I and II). The mesio-distal errors in this study (Orthodontists: 0.09 0.06 mm; Dental students: 0.09 0.09 mm) are comparable to the errors reported in other studies (0.19 0.12 mm;6 0.11 0.30 mm;7 +/- 0.22 mm10). The tip errors we found (Orthodontists: 1.61 1.02 degrees; Dental students: 1.54 1.25 degrees) are comparable to the errors also reported by other investigators (2.57 1.79 degrees;6 5.54 4.32 degrees9), but were greater than those reported by Hodge et al.,7 who reported the smallest angular discrepancies (0.08 0.14 degrees). The initial position of the tooth may influence bracket placement. For example, when a tooth is rotated the error is likely to be in the opposite direction to the direction of rotation. A bracket is more likely to be placed mesially on a tooth with a distal rotation and, conversely, a bracket is more likely to be placed distally on a tooth with a mesio-palatal rotation. If a tooth is palatally placed the error is likely to be incisal and distal. There was also a tendency for all participants to place the brackets with a slight distal tip. The right-left comparisons did not indicate a particular trend in bracket placement. Other investigators have reported a trend for left side bonds (direct and indirect) to be more accurate in the upper arch, and right side bonds to be more accurate in the lower arch.5 It has been stated that errors in bracket placement are related to the skill of the operator, tooth structure, size of the clinical crowns and tooth position.9 This study demonstrated that with a prepared handout even orthodontically inexperienced operators can perform as well as, if not better than, experienced operators in accuracy of bracket placement, albeit at a cost of increased time. This suggests that operator experience may not be an important factor determining the accuracy of bracket positioning.

ACCURACY OF BRACKET PLACEMENT

As mentioned earlier, the present study may have evaluated the influence of clinical experience on the errors of bracket placement. Further studies will be needed to identify if other factors affect the accuracy of bracket positioning.

References
1. 2. Garino F, Garino GB. Computer-aided interactive indirect bonding. Prog Orthod 2005;6:21423. Carlson SK, Johnson E. Bracket positioning and resets: Five steps to align crowns and roots consistently. Am J Orthod Dentofacial Orthop 2001;119:7680. Kalange JT. Ideal appliance placement with APC brackets and indirect bonding. J Clin Orthod 1999;33:51626. Sondhi A. Bonding in the new millennium: Reliable and consistent bracket placement with indirect bonding. World J Orthod 2001;2:10614. Aguirre MJ, King GJ, Waldron JM. Assessment of bracket placement and bond strength when comparing direct bonding to indirect bonding techniques. Am J Orthod 1982;82:26976. Koo BC, Chung C, Vanarsdall RL. Comparison of the accuracy of bracket placement between direct and indirect bonding techniques. Am J Orthod Dentofacial Orthop 1999;116:34651. Hodge TM, Dhopatkar AA, Rock WP, Spary DJ. A randomized clinical trial comparing the accuracy of direct versus indirect bracket placement. J Orthod 2004;31:1327. Taylor NG, Cook, PA. The reliability of positioning preadjusted brackets: an in vitro study. Br J Orthod 1992;19: 2534. Balut N, Klapper L, Sandrik J, Bowman D. Variations in bracket placement in the preadjusted orthodontic appliance. Am J Orthod Dentofacial Orthop 1992;102:627. Fowler PV. Variations in the perception of ideal bracket location and its implications for the preadjusted edgewise appliance. Br J Orthod 1990;17:30510. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets are standards as expected? Angle Orthod 2004;74:4503. Chen S, Chen YX, Li W. A study on the center height of clinical crowns for the people with normal occlusion in Chengdu area. Hua Xi Kou Qiang Yi Xue Za Zhi 2004;22:13841. Muchitsch AP, Droschl H, Bantleon HP, Blumauer D, Stern G. The effect of the vertical bracket position on the orthodontic finish. Fortschr Kieferorthop 1990;51:195203. Andrews LF. The Straight-wire appliance. Br J Orthod 1979;6:12543. Bland, M. An Introduction to Medical Statistics. 3rd edn. Oxford: Oxford University Press. 2000; pp 269272. Poling R. A method of finishing the occlusion. Am J Orthod Dentofacial Orthop1999;115:47687. Bai D, Luo SJ, Chen YX, Xiao LW. The clinic skill in fixed appliance based on characteristics of Chinese normal Occlusion. Hua Xi Kou Qiang Yi Xue Za Zhi 2005;23:324. Henao SP, Kusy RP. Frictional evaluations of dental typodont models using four self-ligating designs and a conventional design. Angle Orthod 2005;75:7585.

3. 4.

Conclusions
1. Orthodontists and senior dental students have similar errors in direct bonding of orthodontic brackets. 2. The provision of clear instructions enabled the dental students to place brackets as accurately as experienced clinicians, although they did require more time to do so. 3. The initial position of a tooth may influence accurate bracket placement, even when there is adequate space for the bracket.

5.

6.

7.

8.

Acknowledgments
The authors would like to thank Ken Tyler for his manufacturing of the photographic jig and the orthodontists and dental students who gave up their time to participate in this study. We would also like to thank 3M Unitek, Australia for providing the orthodontic brackets, and Sydney Dental Hospital and The Dental Board of New South Wales for financial assistance.

9.

10.

11.

12.

Corresponding author
Professor M. Ali Darendeliler Department of Orthodontics Faculty of Dentistry, Sydney Dental Hospital The University of Sydney Level 2, 2 Chalmers Street Surry Hills, NSW 2010 Australia Tel: +61 2 9351 8314 Fax: +61 29351 8336 Email: adarende@mail.usyd.edu.au

13.

14. 15. 16. 17.

18.

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Fracture characteristics of fibre reinforced composite bars used to provide rigid orthodontic dental segments
Soodeh Tahmasbi, * Farzin Heravi and Saied Mostafa Moazzami +
Dental Research Center, Shahid Beheshti University of Medical Sciences, Tehran,* Department of Orthodontics, Mashad University of Medical Sciences, and Department of Restorative Dentistry, Mashad University of Medical Sciences,+ Mashad, Iran

Background: Fibre reinforced composites (FRC) can be used to join teeth as a rigid unit for anchorage purposes and/or for tooth movement. The utility of FRCs for these applications depends on the fracture characteristics and durability of the material under masticatory loads. Aims: To evaluate the effect of simulated masticatory loads on the fracture characteristics of FRC bars joining two bicuspids. Methods: Eighty extracted maxillary bicuspids were used. Pairs of bicuspids were joined with FRC bars on the buccal surfaces. The specimens were divided into two equal groups. In group A the fracture loads of the FRC bars were measured, and in group B the specimens were placed in a simulator and subjected to 4x105 chewing cycles, simulating a 2-year period of mastication. At the conclusion of this test the fracture loads of the FRC bars were measured in the intact specimens. All specimens were examined stereomicroscopically to determine the fracture pattern. Results: There were no bond failures in group B during the simulated masticatory forces. The mean fracture loads in groups A and B were 195.8 N and 190.6 N, respectively. Stereomicroscopic examination showed that most fractures occurred at the enamel-composite interfaces in both groups. There were no significant differences between the groups in the fracture loads and fracture patterns. Conclusions: Fibre reinforced composite bars bonded to bicuspids had sufficient durability to withstand the loads simulating a 2-year period of function. The fracture loads and fracture patterns of the FRC bars were not affected by the loads exerted by the simulator. (Aust Orthod J 2007; 23: 104108)
Received for publication: July 2007 Accepted: September 2007

Introduction
Glass and carbon fibre reinforced polymethylmetacrylate dentures were introduced to clinical dentistry in the 1960s.1,2 Previous studies have reported that FRC has an appropriate flexural modulus,3 flexural strength3,4 and fracture strength5,6 for fixed partial dentures. Fibre reinforced composites have been used in bonded lingual retainers,7,8 in a novel but seldom used glass fibre reinforced composite wire,9 to join adjacent teeth as an anchorage unit or for en masse movement1012 and in space maintainers.13,14 Fibre reinforced composite is relatively straight-forward to use, it is biocompatible and tooth-coloured, and brackets, tubes and hooks can be directly bonded to it.12 It is a material suited
104

to partial or adjunctive orthodontics, particularly in adult patients with advanced periodontal disease or patients who are concerned about the appearance of conventional fixed orthodontic appliances. Although FRC bonded to enamel has acceptable bond strength15 and orthodontic attachments can be bonded to it,16 further information is needed on the behaviour of FRC bars under masticatory loads. During mastication, adjacent teeth often move independently of each other and, as a result, composite bars without fibre reinforcement either fracture or debond.17,18 The addition of fibres to composites has been shown to improve the physical behaviour of the material to such an extent that FRCs are used in prosthodontic bridges.3,4

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Australian Society of Orthodontists Inc. 2007

FRACTURE CHARACTERISTICS OF FRC BARS

Figure 1. Location of the crosshead on the FRC bar.

The aims of this study were to determine if FRC bars bonded to adjacent teeth will remain intact under the loads simulating a 2-year period of intra-oral function, and to determine if the fracture characteristics of FRC bars are affected by simulated masticatory forces.

Materials and methods


In this in vitro study, 80 recently extracted intact maxillary bicuspids with normal anatomy were collected and stored in normal saline solution until required. The teeth were removed from the saline, allowed to dry in air and the roots covered with a 0.10.2 mm thick layer of vinyl polysiloxane impression material (Speedex, Coltene AG, Alstatten, Switzerland). The intention was to create a flexible layer, simulating the periodontal ligament, that would allow the teeth to move independently under simulated masticatory loads.19 Pairs of bicuspids were matched in shape and size and mounted in plastic cylinders (25 mm x 20 mm) with an autopolymerising resin. The bicuspids were mounted with their proximal surfaces in contact, with the marginal ridges at the same level and the central grooves aligned. The buccal surfaces of the bicuspids were cleaned with a rotating prophylaxis brush, pumice and water and the buccal surface of each tooth masked with PVC tape. A 2.5 mm x 4 mm rectangular window in the tape left the central area of the buccal surface clear for etching. The teeth were etched with 35 per cent
Figure 2. A specimen in the simulator.

phosphoric acid for 20 seconds, rinsed for 10 seconds and dried with air. A thin layer of bonding resin (Excite, Ivoclar-Vivadent, Schaan, Liechtenstein) was applied and cured with a light unit (Astralis-7, Ivoclar-Vivadent, Schaan, Liechtenstein) using the low power program (400 mW/cm2) for 20 seconds. Tetric-Ceram composite (Ivoclar-Vivadent, Schaan, Liechtenstein) was then applied to the resin. A 3 mm x 12 mm strip of Ribbond (Ribbond Inc, Seattle, Washington) saturated with the bonding resin was adapted to the composite. Any composite expressed outside the strip was removed. Next, a thin layer of a flowable composite (Tetric-Flow, Ivoclar-Vivandent, Schaan, Liechtenstein) was applied to the fibre/composite combination and cured with the Astralis-7 unit using the high power program (750 mW/cm2) for 40 seconds. The curing unit was placed on the buccal aspect of each tooth. The procedure was repeated for all specimens.
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TAHMASBI ET AL Table I. Fracture strengths of the FRC bars linking two bicuspids.

80 70 60 Frequency 50 40 30 20 10 0 A Groups B 1 2 3 4 Pattern of fracture

Group

Total

Mean (N)

SD (N)

SEM (N)

A B

20 20

195.8 190.6

14.34 24.03

3.21 5.37

Student t-test, not significant

2. Cohesive failure in the composite material between FRC and enamel surface (composite exposed on more than 75 per cent of both fractured surfaces). 3. Adhesive failure at the FRC interface (FRC exposed on more than 75 per cent of one of the fractured surfaces). 4. Cohesive failure within the FRC (FRC exposed on more than 75 per cent of both fractured surfaces). The fracture patterns in the groups were compared with the Chi-square test.

Figure 3. Pattern of failure. 1. Adhesive failure at the enamel-composite interface. 2. Cohesive failure in composite between enamel surface and FRC. 3. Adhesive failure at the FRC interface. 4. Cohesive failure in the FRC.

Results
After 24 hours storage in normal saline, the specimens were randomly divided into two equal groups. In group A, the fracture load (N) of each FRC bar was measured with a universal testing machine (Instron Corp, Canton, Mass) at a crosshead speed of 5 mm/min. The specimens were oriented in the positioning jig so that the blade of the crosshead loaded the FRC bar vertically at the midpoint interdentally (Figure 1). The specimens in Group B were placed in a chewing simulator machine operated for 4x105 cycles at 14 N loads with a frequency of 3 Hz and duration of 0.2 seconds. This simulated two years of mastication (Figure 2).20 At the conclusion of this test specimens were inspected for bond failure or fracture, and the ratio of intact specimens to initial specimens reported as the survival rate. The load (N) required to fracture each intact specimen was then determined using the methods described for group A. The data obtained for the groups were compared with the Student t-test. Each specimen was then examined with a stereomicroscope (Olympus SZH10, Tokyo, Japan) at x10 magnification and the fracture pattern classified as follows: 1. Adhesive failure at the enamel surface (enamel exposed on more than 75 per cent of one of the fractured surfaces). As all specimens in Group B were intact at the end of the test simulating the forces of mastication the survival rate of the FRC bars was 100 per cent. The mean loads required to fracture the specimens in groups A and B were 195.8 N (SD: 14.34) and 190.6 N (SD: 24.03) respectively (Table I). There was no significant difference between the mean fracture loads of the two groups (p > 0.05). The distributions of the fracture patterns in the two groups are shown in Figure 3. In both groups most fractures occurred at the enamel-composite interface. The Chi-square test revealed that the fracture pattern was independent of the groups: i.e. the fracture pattern was similar in both groups.

Discussion
Fibre-reinforced composite bars can be used to join teeth to form rigid anchorage units or units for active tooth movement. This study was designed to determine if FRC bars bonded to adjacent bicuspids would survive the loads simulating two years of mastication, and to determine if the fracture characteristics of the FRC bars were affected by the simulated masticatory forces. The results indicated that FRC bars linking the bicuspids had sufficient durability to withstand the simulated masticatory forces, and these forces did not have adverse effects on the fracture

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FRACTURE CHARACTERISTICS OF FRC BARS

characteristics of FRC bars. Although previous studies have demonstrated the durability of FRC fixed partial dentures under chewing forces,6 no similar study has been carried out on the survival rate of posterior teeth joined with FRC. In our study, we attempted to reproduce the periodontal ligament by covering the roots of the teeth with a thin layer of vinyl polysiloxane impression material. We assume the flexible layer allowed the teeth to move independently of each other under the simulated masticatory loads. The FRC connecting bars had sufficient strength and durability to remain intact for the entire period of the study. Fallis and Kusy,9 in a short-term clinical study, found no fractures in fibre reinforced composite wires used for retainers, but Rose et al.8 reported that the survival time of FRC lingual orthodontic retainers was only 11.5 months. The FRC bars had fracture loads between 190 and 195 N, which compares favourably with the range of forces (45 to 120 N) experienced during mastication.21,22 We consider that FRC bars may have sufficient fracture strength to tolerate normal masticatory forces but not maximum biting loads, which can be more than 500 N.23,24 Patients should be warned that FRC bars are likely to fail if they are subjected to heavy biting forces that may occur during bruxism and clenching. The same situation applies to most bonded attachments and retainers.25 Stereomicroscopic examination of the fracture areas in both groups showed that the majority of fractures occurred at the enamel-composite interface (Figure 3). The patterns of failure were estimated so one must acknowledge that some bias may have occurred in our judgements of the sites of failure. Using the data we collected we were unable to demonstrate any significant difference in fracture pattern. It is noteworthy that in the latest generation of preimpregnated FRC bars, the fibres and the resinous matrix are coupled during the manufacturing process. This process results in a higher concentration of fibres, more complete wetting, fewer voids and reduced chair time when placing FRC bars, as compared with the FRC method we used.26 Based upon the results of the present study we suggest clinical investigations are now needed to determine the value of FRC bars bonded to two or more teeth.

Conclusions
Fibre reinforced composite bars linking bicuspids had sufficient durability to withstand the loads simulating a 2-year period of function. The fracture loads and fracture patterns of the FRC bars were not affected adversely by the loads exerted by the simulator.

Acknowledgment
The authors would like to thank Dr Fazli Bazzaz, Vice-Chancellor of Research, Mashad University of Medical Sciences, for her support and encouragement.

Corresponding author
Dr S. Tahmasbi Dental Research Center School of Dentistry Shahid Beheshti University of Medical Sciences Tehran Iran Tel: +9821 2241 3897 Fax: +9821 2242 7753 Email: dr_s_tahmasbi@yahoo.com

References
1. Smith DC. Recent developments and prospects in dental polymers. J Prosthet Dent 1962;12:106678. 2. Manley TR, Bowman AJ, Cook M. Denture bases reinforced with carbon fibers. Br Dent J 1979;146:258. 3. Goldberg AJ, Freilich MA, Haser KA, Audi JH. Flexure properties and fiber architecture of commercial fiber reinforced composites. J Dent Res 1998;77:226. 4. Freilich MA, Karmaker AC, Burstone CJ, Goldberg AJ. Flexure strength of fiber-reinforced composites designed for prosthodontic application. J Dent Res 1997;76:138. 5. Behr M, Rosentritt M, Latzel D, Kreisler T. Comparison of three types of fiber-reinforced composite molar crowns on their fracture resistance and marginal adaptation. J Dent 2001;29:18796. 6. Kolbeck C, Rosentritt M, Behr M, Lang R, Handel G. In vitro examination of the fracture strength of 3 different fiber-reinforced composite and 1 all-ceramic posterior inlay fixed partial denture systems. J Prosthodont 2002;11: 24853. 7. Diamond M. Resin fiberglass bonded retainer. J Clin Orthod 1987;21:1823. 8. Rose E, Frucht S, Jonas IE. Clinical comparison of a multistranded wire and a direct bonded polyethylene ribbon-reinforced resin composite used for lingual retention. Quintessence Int 2002;33:57983. 9. Fallis DW, Kusy RP. Novel esthetic bonded retainers: a blend of art and science. Clin Orthod Res 1999;2:2008. 10. Burstone CJ, Kuhlberg AJ. Fiber-reinforced composites in orthodontics. J Clin Orthod 2000;34:2719.

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11. Cacciafesta V, Sfondrini MF. One-appointment correction of a scissor bite with 2D lingual brackets and fiber-reinforced composites. J Clin Orthod 2006;40:40911. 12. Uribe F, Nanda R. Treatment of bimaxillary protrusion using fiber-reinforced composites. J Clin Orthod 2007;41:2732. 13. Zuccati G, de Barros e Silva Mda G, Doldo T, Savastano C. Fiber-reinforced composite space maintenance for anterior implant therapy. J Clin Orthod 2007;41:33640. 14. Kargul B, Caglar E, Kabalay U. Glass fiber-reinforced composite resin as fixed space maintainers in children: 12-month clinical follow-up. J Dent Child 2005;72:10912. 15. Meiers JC, Kazemi RB, Donadio M. The influence of fiber reinforcement of composites on shear bond strengths to enamel. J Prosthet Dent 2003;89:38893. 16. Freudenthaler JW, Tischler GK, Burstone CJ. Bond strength of fiber-reinforced composite bars for orthodontic attachment. Am J Orthod Dentofacial Orthop 2001;120: 64853. 17. Zachrisson BU. The acid etch technique in orthodontics: clinical studies. In: Silverstone LM, Dagon L, eds. Proceedings of an international symposium on the acid etch technique. St Paul, 26575. Minn: North Central, 1975. 18. Rosenberg S. A new method for stabilization of periodontally involved teeth. J Periodontol 1980;51:46973.

19. Pitts DL, Matheny HE, Nicholls JI. An in vitro study of spreader loads required to cause vertical root fracture during lateral condensation. J Endod 1983;9:54450. 20. Outhwaite WC, Twiggs SW, Fairhurst CW, King GE. Slots vs pins: a comparison of retention under simulated chewing stresses. J Dent Res 1982;61:4002. 21. Mizrahi E, Smith DC. Direct attachment of orthodontic brackets to dental enamel: A preliminary clinical report. Br Dent J 1971;130:3926. 22. Newman GV. Epoxy adhesives for orthodontic attachments: progress report. Am J Orthod 1965;51:90112. 23. Hidaka O, Iwasaki M, Saito M, Morimoto T et al. Influence of clenching intensity on bite force balance, occlusal contact area, and average bite pressure. J Dent Res 1999;78: 133644. 24. Reynolds IR. A review of direct orthodontic bonding. Br J Orthod 1975; 2:1718. 25. Bin Abdullah MS, Rock WP. The effect of etch time and debond interval upon the shear bond strength of metallic orthodontic brackets. Br J Orthod 1996;23:1214. 26. Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiberreinforced composites in clinical dentistry. Chicago: Quintessence, 2000:13.

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Assessment of palatal bone thickness in adults with cone beam computerised tomography
Antonio Gracco, Lombardo Luca, Mauro Cozzani and Giuseppe Siciliani
Department of Orthodontics, University of Ferrara, Ferrara, Italy

Aims: To determine the most suitable region of the palate for the insertion of miniscrews. Methods: The subjects were 72 adult patients between 20 and 44 years of age. The thickness of the bony palate was determined with digital volumetric tomography. Bone thickness was measured 4, 8, 16 and 24 mm posterior to the incisive foramen and 0, 3, and 6 mm lateral to the midline of the palate. Results: The thickest bone was found 4 mm behind and 6 mm lateral to the incisive foramen. The bone thinned progressively from anterior to posterior and from medial to lateral. A median ridge of bone was present in the 8, 16 and 24 mm sections. In these sections the thickest bone was close to the suture. Conclusion: The hard palate offers several suitable sites for the insertion of miniscrews for orthodontic purposes. The areas behind the incisive foramen and to one side of the median palatal suture have adequate bone for miniscrews. (Aust Orthod J 2007: 23; 109113)
Received for publication: August 2007 Accepted: September 2007

Introduction
Miniscrews can be placed in many different intra-oral bony sites. Once placed they can be used immediately, without having to wait for osseointegration. Several studies have been carried out to determine the ideal sites for insertion of the miniscrews.13 In the maxilla the palate is considered a suitable site for miniscrews because of its structure and ease of access.47 With the exception of the incisive canal region, the median and paramedian areas of the palate consist of thick, dense bone capable of supporting one or more miniscrews and orthopaedic loads.8 In these areas there are no anatomical structures, such as nerves, blood vessels or dental roots, which may impede the insertion of miniscrews or lead to complications.9,10 The soft tissue in the midline of the palate between the first and second premolars is, on average 3.06 +/0.45 mm thick.2 The thickness and intrinsic characteristics of the palatal mucosa may enhance the stability of a miniscrew inserted in this area.9,10 Early implants for stable anchorage required a flap operation for insertion and removal, could only be placed in the anterior region of the palate and could not be
Australian Society of Orthodontists Inc. 2007

loaded until osteointegration had occurred.5,1117 Miniscrews have successfully overcome these disadvantages. For example, Kyung et al.10 successfully used a miniscrew inserted into the median zone of the palate to distalise upper molars, and Lee et al.18 used palatal miniscrews to intrude teeth. However, miniscrews less than 2 mm in diameter may not be stable in this site.19,20 Miniscrews have a place in facilitating other forms of orthodontic treatment. For example, palatal miniscrews have been used to facilitate distal movement of the anterior teeth in lingual treatment, and have been used with a modified pendulum appliance to distalise the upper teeth.21,22 The Graz implant-supported pendulum appliance uses miniscrews and a titanium miniplate to distalise the upper molars.23 The bone in the anterior region of the midline of the palate is considered an ideal site for insertion of a miniscrew, but there is a lack of detail about the thickness of palatal cortical bone antero-posteriorly and medio-laterally, particularly in adults.11,24 In the present study we aim to use cone beam technology to determine the thickness of the palatal bone at four levels posterior to the incisive foramen. At each level
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Figure 1. Paracoronal sections 4, 8, 16 and 24 mm posterior to the incisive foramen.

when compared with a conventional CT.2526 The settings used were: 12 inch field of view, 110 kVp (AP-LL), 2.00 mA (AP) e 1.00 mA(LL), exposure time 5.4 s, slice thickness 0.50 mm. Using the NNT Newtom 3G software, we identified the incisive foramen on the axial section of the upper jaw for each subject. Paracoronal views of the palatal region were reconstructed at 4, 8, 16 and 24 mm posterior to the incisive foramen. Measurements of the bone height were then made at the median palatal suture, and 3 mm and 6 mm on both sides of and at right angles to the suture (Figures 1 and 2). Twenty measurements for each patient were made on the computer display monitor with the Newtom 3G measurement software. The measurements of palatal height in 27 patients were carried out by two different investigators. The method error was determined with Dahlbergs formula and the systematic error with the Students t-test, where p < 0.05 was considered significant. On average, the method errors of the measurements at the suture were 0.54 (p = 0.062), 3 mm on right and left sides of the suture it was 0.55 mm (p = 0.478) and 0.43 mm (p = 0.654) respectively, and 6 mm on the right and left sides of the suture it was 0.57 mm (p = 0.116) and 0.54 mm (p = 0.152) respectively. No statistically significant difference was found in any of these cases.

Figure 2. Rendering of a 16 mm paracoronal view.

bone thickness will be measured at the suture 3 and 6 mm on both sides of and at right angles to the median palatal suture.

Material and methods


The digital volumetric tomograms of 72 healthy adults (34 males, 38 females), between 20 and 44 years of age, were randomly selected from the files held in the Postgraduate School of Orthodontics of the University of Ferrara. We excluded subjects with craniofacial malformations and/or syndromes, individuals with a history of facial trauma and those who had undergone surgery to the facial structures. Data were obtained using the Newtom 3G Volume Scanner QRsr1 Verona, a cone beam X-ray machine. Images obtained from this scanner have the advantages of sufficient detail and a lesser radiation dosage

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right sides of the suture also thinned as the sections moved from anterior to posterior. Considerable variation in bone thickness was found in all sections. For example, in one subject there was 6 mm of bone (6 mm to the left) in the 24 mm section and at the same site in another subject the bone was only 1 mm thick. At the suture, no significant differences in mean bone thickness were found between the 4 mm and the 8 mm paracoronal sections or between the 16 and 24 mm paracoronal sections. Bone in the former two sections was, on average, thicker than the bone in the latter two sections.

Bone thickness medio-laterally


The mean palatal bone thicknesses calculated for each section (4, 8, 16 and 24 mm from the incisive foramen) at 3 and 6 mm to the right and left of the suture were compared using the Kruskal-Wallis test. No significant differences were found between the left and the right sides of the palate. We compared bone thickness at the suture and 3 mm and 6 mm to the right and left of the suture in each patient and in each paracoronal section of the palate using the Kruskal-Wallis test. In the sample we found that the bone at the suture in the 24 mm section was significantly thicker than that found at 6 mm on the right and left sides of the suture. In all other cases the bone at the suture was not significantly thicker than the bone 3 mm and 6 mm on the right and left sides of the suture. We also compared the thickness bone 3 mm to the left of the suture with that found at 6 mm to the left of the suture in each section (4, 8, 16 and 24 mm) in each patient, and then repeated the comparisons for the right side of the palate. No statistically significant differences were found.

Figure 3. The mean palatal bone thicknesses at different distances from the incisive foramen (4, 8, 16 and 24 mm) and 0, 3 and 6 mm on both sides of the suture. The vertical bars denote 0.95 confidence intervals.

Taking into account that the distribution of the sample was not normal or symmetrical, the KruskalWallis test was used to highlight any differences within the sample in relation to side (right/left), distance from the midline (3 mm/6 mm), or linked to the different sections/levels (4, 8, 16 and 24 mm from the incisive foramen).

Results
The means and the standard deviations of palatal bone thickness in the sample are reported in Table I and Figure 3. Considerable variation in bone thickness was found at all sites. There were no statistically significant differences in the thickness of palatal bone in the male and female patients.

Discussion
To understand how the morphology of the palate changes antero-posteriorly and medio-laterally we measured the thickness of the cortical bone in four paracoronal sections (4, 8, 16, and 24 mm from the incisive foramen) taken with a cone beam X-ray machine. The thickest bone (approximately 1 cm) was found in the most anterior and lateral sites, that is 4 mm behind the incisive foramen and 6 mm lateral to median palatal suture. Although the bone thinned

Bone thickness antero-posteriorly


The bone in the midline of the palate was, on average, 8 mm thick 4 mm behind the incisive foramen. The midline bone thickness fell, on average, to 67 mm 8 mm behind the foramen and to 56 mm 16 and 24 mm behind the foramen. The thickness of the bone 6 mm and 3 mm on the left and

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Table I. Palatal bone thickness.

Distance from median suture

Distance from incisive foramen (mm)

Mean

SD

Min

Max

6 mm R

4 8 16 24 4 8 16 24 4 8 16 24 4 8 16 24 4 8 16 24

10.4 5.6 2.8 2.4 8.3 5.1 2.9 2.9 8.7 6.6 4.0 3.9 8.3 5.2 2.9 2.8 10.0 5.8 2.7 2.3

3.24 2.38 1.01 0.87 3.04 1.89 0.85 1.27 3.16 2.03 1.36 1.66 2.88 2.05 1.26 1.19 3.16 2.13 1.23 0.91

3.8 1.7 1.3 0.8 2.9 1.7 1.7 1.3 2.9 2.5 1.7 1.3 2.8 1.7 0.8 1.3 3.4 1.7 1.2 1.0

18.9 11.3 5.9 5.0 16.4 10.2 6.7 6.9 17.2 10.9 8.0 8.5 16.4 10.4 6.7 5.9 19.3 11.0 7.6 6.3

and 15 years of age.28 In agreement with our present findings we found that the thickest bone in children and adolescents was in the most anterior part of the palate 6 mm to the right and left of the median palatal suture. While the bone in the posterior region of the palate was markedly thinner it is in the form of two plates of bone. The overlying mucosa in this area is also thinner. Because of these factors this area can support an appropriately sized miniscrew. The length of a miniscrew is thought to be an important factor in screw stability. In the anterior region of the palate, miniscrews with a functional (threaded) part of approximately 10 mm can be used, although we found in some individuals the bone in this area was very thin. Eight millimetres behind the incisive foramen, the functional part can, on average, be at least 8 mm in length, while in the posterior part of the palate (1624 mm from the incisive foramen) 45 mm miniscrews can be used in some individuals. The length of a miniscrew should also take into account the thickness of the palatal mucosa, which is thickest in the mid-palatal suture area 4 mm behind the incisive papilla. Moving posterior from the papilla the mucosa is consistently 1 mm thick, which is a favourable thickness for a miniscrew.27 This study highlights the importance of selecting the correct length of miniscrew so that both cortical plates are engaged by the screw and the nasal cavity is not penetrated. To ensure that screws do not loosen it has been suggested that the diameter of a palatal screw should be no less than 2 mm.20 Miniscrews with smaller diameters (1.21.3 mm) may be justified if they are to be placed in inter-radicular alveolar bone where there is a risk of damage to the roots of the teeth. However, in the midpalate there are no blood vessels, nerves and other structures likely to interfere with insertion or cause complications when large diameter miniscrews are used. There is a general consensus that the suture, despite being one of thickest sites in the palate, is not suitable for insertion of miniscrews due to incomplete calcification. Even in adult subjects the possibility exists that connective tissue in the suture might become interposed between a screw and the surrounding bone and cause the screw to loosen.48 The sites adjacent to the suture offer better sites for placement of miniscrews. The greater density and resistance of the bone adjacent to the suture compensates for the thinner bone found posteriorly and laterally.

3 mm R

Suture

3 mm L

6 mm L

progressively from anterior to posterior and from medial to lateral, a marked ridge of bone was left in the vicinity of the suture. This median ridge of bone was 67 mm thick 8 mm behind the foramen, but only 4 mm thick in the 16 and 24 mm sections. The bone in the most lateral sites (i.e. 6 mm lateral to the median palatal suture) also thinned progressively from anterior to posterior and from medial to lateral. Bone thickness fell from approximately 1 cm in the 4 mm paracoronal section, to 56 mm in the 8 mm section, to 23 mm in the 16 and 24 mm sections. Our findings agree with and extend the work reported by previous studies of palatal bone thickness in children and adolescents.2,2729 In our previous study, we measured the thickness of the palatal bone in paracoronal sections in patients between 10
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Conclusions
Although the bone forming the palate thins progressively from anterior to posterior and from medial to lateral, the bone in the posterior part of the palate is suitable for the insertion of screws of appropriate diameter and length. The bone in the latter site is laid down in the form of two plates.

Corresponding author
Dr Antonio Gracco Via E. Scrovegni 2 35100 Padova Italy Tel: +39 0532 202 528 Fax: +39 0532 202 528 Email: antoniogracco@libero.it

References
1. Poggio PM, Incorvati C, Velo S, Carano A. Safe Zones: A guide for miniscrew positioning in the maxillary and mandibular arch. Angle Orthod 2006;76:1917. 2. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary anchorage devices. Semin Orthod 2005;11:1015. 3. Deguchi T, Nasu M, Marakami K, Yabuuchi T, Kamioka H, Takano-Yamamoto T. Quantitative evaluation of cortical bone thickness with computed tomographic scanning for orthodontic implants. Am J Orthod Dentofacial Orthop 2006;129:721.e712. 4. Wehrbein H, Glatzmaier J, Mundwiller U. Diedrich P. The Orthosystem: a new implant system for orthodontic anchorage in the palate. J Orofac Orthop 1996;57:14253. 5. Wehrbein H, Merz BR, Hmmerle CH, Lang NP. Bone-toimplant contact of orthodontic implants in humans subjected to horizontal loading. Clin Oral Implants Res 1998;9: 34853. 6. Wehrbein H, Feifel H, Diedrich P. Palatal implant anchorage reinforcement of posterior teeth: a prospective study. Am J Orthod Dentofacial Orthop 1999;116:67886. 7. Wehrbein H, Merz BR, Diedrich P, Glatzmaier J. The use of palatal implants for orthodontic anchorage. Design and clinical application of the Orthosystem. Clin Oral Implants Res 1996;7:4106. 8. Wehrbein H, Merz BR, Diedrich P. Palatal bone support for orthodontic implant anchorage a clinical and radiological study. Eur J Orthod 1999;21:6570. 9. Misch CE. Contemporary implant dentistry, 2nd ed., Mosby, St. Louis, 1999, p. 113. 10. Kyung SH, Hong SG, Park YC. Distalization of maxillary molars with a midpalatal miniscrew. J Clin Orthod 2003;37: 226. 11. Bernhart T, Vollgruber A, Gahleitner A, Drtbudak O, Haas R. Alternative to the median region of the palate for placement of an orthodontic implant. Clin Oral Implants Res 2000;11:595601. 12. Schlegel KA, Kinner F, Schlegel KD. The anatomic basis for palatal implants in orthodontics. Int J Adult Orthod Orthognath Surg 2002;17:1339.

13. Martin W, Heffernan M, Ruskin J. Template fabrication for a midpalatal orthodontic implant: technical note. Int J Oral Maxillofac Implants 2002;17:7202. 14. Tosun T, Keles A, Erverdi N. Method for the placement of palatal implants. Int J Oral Maxillofac Implants 2002;17: 95100. 15. Bantleon H, Bernhart T, Crismani AG, Zachrisson BU. Stable orthodontic anchorage with palatal osseointegrated implants. World J Orthod 2002;3:10916. 16. Cousley R. Critical aspects in the use of orthodontic palatal implants. Am J Orthod Dentofacial Orthop 2005;127:7239. 17. Gedrange T, Bourauel C, Kobel C, Harzer W. Three-dimensional analysis of endosseous palatal implants and bones after vertical, horizontal, and diagonal force application. Eur J Orthod 2003;25:10915. 18. Lee J-S, Kim DH, Park Y-C, Kyung S-H, Kim T-K. The efficient use of midpalatal miniscrew implants. Angle Orthod 2004;74: 71114. 19. Melsen B. Mini-implants: Where are we? J Clin Orthod 2005;39:53947. 20. Carano A, Velo S, Leone P, Siciliani G. Clinical implication of the miniscrew anchorage system. J Clin Orthod 2005;39: 924. 21. Park H-S. A miniscrew-assisted transpalatal arch for use in lingual orthodontics. J Clin Orthod 2006;40:1216. 22. Kircelli B H, Pektas Z, Kircelli C. Maxillary molar distalization with a bone-anchored pendulum appliance. Angle Orthod 2006;76:6509. 23. Kinzinger G, Wehrbein H, Byloff F K, Yildizhan F, Diedrich P. Innovative anchorage alternatives for molar distalization an overview. J Orofac Orthop 2005;66:397413. 24. Yildizhan F. Strukturparameter des medianen gaumens und orthodontische verankerungsimplantate. Eine radiologische, histologische und histomorphometrische Studie. Med Diss Aachen 2004. 25. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A new volumetric CT machine for dental imaging based on the cone beam technique: preliminary results. Eur Radiol 1998; 8:155864. 26. Hatcher DC, Aboudara CL. Diagnosis goes digital. Am J Orthod Dentofacial Orthop 2004;125:5125. 27. Kim HJ, Yun HS, Park HD, Kim DH, Park YC. Soft-tissue and cortical-bone thickness at orthodontic implant sites. Am J Dentofacial Orthop 2006;130:17782. 28. Gracco A, Lombardo L, Cozzani M, Siciliani G. Quantitative evaluation with CBCT of palatal bone thickness in growing patients. Prog Orthod 2006; 7:16474. 29. King K. Paramedian palate morphology in the adolescent: a cone beam computer tomography study. Am J Orthod Dentofacial Orthop 2005;128:262.

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Vertical changes in treated and untreated Class II division 1 malocclusions


Craig Sharp, * Michael Harkness and Peter Herbison
Specialist practice, Auckland,* Oral Health, Canterbury District Health Board, Christchurch and Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand

Background: Treatment-induced increases in the height of the face may be permanent. Aims: To determine if appliance-induced increases in the heights of the upper and lower molars in girls with Class II division 1 malocclusion, and the consequential increase in the height of the face are maintained. Methods: Ten angles and 10 distances were measured on lateral cephalometric radiographs of 11 year-old girls (Range: 8.514.8 years) with treated (N = 9) and untreated (N = 8) Class II division 1 malocclusions. The intervals between the initial and recall records were, on average, 12 years (Range: 7.615.7 years) for the girls in the treatment group, and 8 years (Range: 413 years) for the girls in the untreated/control group. In the treatment group eight girls were treated with the Begg appliance and Class II elastics. Results: Upper and lower molar dentoalveolar heights in both groups increased significantly between the initial and recall visits. There were no significant differences between the molar heights in the groups at the start or at recall. Anterior face height (AFH) also increased significantly in both groups between the initial and recall visits. At recall, AFH in the treatment group was significantly greater than AFH in the control group. This finding is attributed to a similar-sized difference between the groups at the start, to the longer period between the initial and recall records in the treatment group and to lesser variation in both groups at recall. In both groups, posterior face height increased significantly between the initial and recall stages. At the conclusion of the study there were no statistically significant differences between the treated and control groups in either overjet or the inclination of the upper incisors. Relapse of the upper incisors in the treatment group and retroclination of the upper incisors in the control group reduced the initial differences between the groups. These changes are attributed to altered lip posture and increased lip pressures in adolescence. At recall, angles SNA and SNB were significantly smaller in the treatment group. Conclusion: The heights of the upper and lower molars and the face increased in both groups. Orthodontic treatment may have no lasting effects on either the height of the face or the heights of the molars in girls with Class II division 1 malocclusion. (Aust Orthod J 2007; 23: 114120)
Received for publication: September 2007 Accepted: October 2007

Introduction
Almost 70 years ago Brodie, Downs, Goldstein and Myer1 published the first cephalometric appraisal of patients treated with the edgewise appliance. In 12 patients with Class II division 1 malocclusions they noted that in every case the anterior end of the occlusal plane tipped downwards during treatment, opening the angle between the Bolton and occlusal planes. They reported also that following treatment the angulations of the teeth and occlusal plane tended to recover. They found Class II elastics opened the angle between the Bolton and occlusal planes and Class III elastics closed it, and a downward and
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backward rotation of the mandible occurred in a number of cases. Other studies have confirmed that elevation of the molars during orthodontic treatment is accompanied by an increase the height of the face, a downward and backward rotation of the mandible and downward tipping of the anterior end of the occlusal plane, particularly if Class II elastics are used.29 On one hand it has been argued that the increase in face height may be permanent and on the other hand that it is reversible.8,10,11 The evidence is, however, inconclusive because only a few studies have used Class II division 1 malocclusion controls, the few prospective
Australian Society of Orthodontists Inc. 2007

VERTICAL CHANGES IN CLASS II DIVISION 1 MALOCCLUSIONS

Table I. Ages of the control and treatment groups.

Control Mean (SD) (years) Range Min Max Mean (SD) (years)

Treatment Range Min Max

Age initial records Age end of treatment Retention period Age recall records End recall Initial recall

11.9 (2.20)

8.5

14.8

20.2 (4.02) 8.3 (2.84)

14.4 4.0

27.4 13.1

11.7 14.7 1.9 23.8 7.2 12.1

(1.74) (1.59) (0.70) (2.74) (1.81) (2.66)

9.1 12.9 1.0 20.7 5.3 7.6

14.5 17.0 3.1 28.6 10.6 15.7

studies of Class II division 1 treatment have either not reported vertical changes and/or the subjects have not been followed long-term. The aim of this retrospective study is to determine if appliance-induced increases in the heights of the molars and the consequential increase in the height of the face are maintained.

Subjects and methods


The subjects were girls with Class II division 1 malocclusions referred to the Department of Orthodontics, University of Otago between 1970 and 1981.12 The following inclusion criteria were used: 1. Class II division 1 malocclusion12 with an incisor overjet > 5 mm at the initial consultation. Overjet was measured on study casts taken at the initial consultation. 2. Lateral cephalometric radiographs taken at the start and end of treatment, and at least five years from the end of treatment (if no retention was used) or five years from the cessation of all retention. 3. Lateral cephalometric radiographs taken at the initial consultation for the girls who did not have treatment, and at least 3.5 years after the initial consultation. 4. All radiographs were taken with the teeth in the intercuspal position. Of the 41 girls who met these criteria 30 had been treated and 11 had not been treated. After ethical approval had been obtained attempts were made to trace the girls through School of Dentistry records, past telephone directories, family members and the New Zealand electoral roll. Eventually, nine girls who had been treated (Treatment group) and eight girls

who had not been treated (Control group) were traced, and agreed to return for the recall records. In the treatment group five girls were treated with the Begg appliance and four first premolar extractions; one girl with four first premolar extractions, the Begg appliance and headgear; one girl was treated nonextraction with headgear and the Begg appliance; one girl with four first premolar extractions and removable appliances; and one girl with two upper first premolar extractions, the Begg appliance and headgear. At the initial consultation the mean ages of the girls were: Treatment group 11.7 years (SD: 1.74) and the Control group 11.9 years (SD: 2.20). The ages at each stage and the intervals between the various stages are given in Table I.

Methods
The radiographs were taken with either a Margolis cephalostat with a Meyer anode-generator (up to 1978) or a Wehmer cephalostat with an Amrad-Craig 1 anode-generator (from late 1978). Because the cephalostats had different tube-subject and subjectfilm distances, the enlargements of both machines were calculated from radiographs of the same wire mesh positioned midway between the ear posts. Image magnification in the Margolis cephalostat was 1.1287 and in the Wehmer cephalostat it was 1.0866. As the majority of the radiographs were taken with the Margolis equipment all linear measurements on radiographs taken with the Wehmer cephalostat were converted to the same magnification as those taken with the Margolis cephalostat. Angular dimensions were not affected by the different magnifications of the two cephalostats. No difficulty was experienced identifying which cephalostat had been used because the film sizes and images of the ear posts were different.
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Figure 1. Reference points and measurements. SNA: sella-nasion-A point (1-2-4) SNB: sella-nasion-B point (1-2-9) ANB: A point-nasion-B point (4-2-9) MxL/MnL: ANS-PNS/Me-Go (3-13/10-11) FH/MxL: Or-Po/ANS-PNS (18-19/10-11) FH/MnL: Or-Po/Me-GO (18-19/10-11) OL/MxL: ANS-PNS/U6DCT-PMCT (14-16/3-13) OL/MnL: U6DCT-PMCT/Me-GO (14-16/10-11) UI/MxL: UIA-UIE/ANS-PNS (5-6/3-13) LI/MnL: LIE-LIA/Me-Go (7-8/10-11) Overjet: UIE-LL (6-20) Overbite: LIE-LL (7-20) UIperp/MxL: UIE perp/ANS-PNS (6/3-13) U6perp/MxL: U6MCT perp/ANS-PNS (15/3-13) LIperp/MnL: LIE perp/Me-Go (7/10-11) L6perp/MnL: LIE perp/ANS-PNS (17/10-11) AFH: N-Me (2-10) PFH: S-Go (1-11) UIperp/OL: UIE perp/U6DCT-PMCT (6/14-16) LIperp/OL: LIE perp/U6DCT-PMCT (7/14-16)

were calculated with Dahlbergs formula, and differences between the two sets of measurements with the paired t-test.13 Significant differences at the 5 per cent level of significance were found for the variables: OL/MxL, OL/MnL, and the perpendicular distance from the incisal edge of the upper incisor to the maxillary plane (UIperp/MxL). The mean difference for OL/MxL was 0.81 degree (SEM difference: 0.17 degree), for OL/MnL it was 0.65 degree (SEM difference: 0.24 degree) and for UIperp/MxL it was 0.20 mm (SEM difference: 0.11 mm). In agreement with Baumrind and Frantz,14 we consider that large dental restorations affected our ability to locate the reference points for the occlusal plane consistently. The significant finding for the upper incisor dentoalveolar height (UIperp/MxL) may be due to a slight shift in location of the reference points for this dimension. In spite of these differences we consider that the method of measurement met the requirements of the study. Poor definition on the films taken with the older Margolis equipment did not allow us to use stable anatomical structures. Comparisons between the Initial, End and Recall measurements in the Treatment sample were carried out in two steps: an analysis of variance was used to determine if any statistically significant differences (p < 0.05) occurred between the same measurements at the three stages. Duncans new multiple range tests were then carried out to determine whether the significant differences occurred between the Initial End, End Recall and/or Initial Recall stages. Comparisons within the Control group were carried out with paired t-tests, and between the Control and Treatment groups with t-tests for unpaired data. The 0.05 level of probability was used in all tests.

The coordinates of the reference points shown in Figure 1 were digitised directly three times with a reflex metrograph. The cursor was moved several centimetres away from each point between digitisations. The means of the three digitisations were used to calculate the measurements described in the legend to Figure 1. To estimate the errors in the method of measurement, 10 radiographs were randomly selected from the Control and Treatment groups and digitised using the methods described above. The same radiographs were redigitised eight days later. The combined errors in identification of the reference points and digitisation
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Results
The means and standard deviations of the variables together with the comparisons within and between the groups are given in Table II. The groups significantly different with Duncans multiple range test are indicated by letters.

Control group
Initial Recall No statistically significant differences were found between the angular measurements at the initial and recall stages. There were, however, statistically significant increases in upper molar dentoalveolar height

VERTICAL CHANGES IN CLASS II DIVISION 1 MALOCCLUSIONS

Table II. Comparison of the cephalometric variables in the control and treatment groups.

Variables Initial Mean (SD)

Control (N=8) Recall Mean (SD) Initial Mean (SD)

Treatment (N=9) End Mean (SD) Recall Mean (SD)

Control vs Treatment Initial p Recall p

Angles

p*

SNA SNB ANB MxL/MnL FH/MxL FH/MnL OL/MxL OL/MnL UI/MxL LI/MnL Distances Overjet Overbite

82.3 (4.08) 77.3 (3.02) 5.0 (1.46) 27.1 (3.69) 2.5 (2.25) 26.5 (4.09) 13.0 (3.69) 14.1 (5.24)

81.8 (2.01) 77.0 (1.26) 4.8 (1.78) 25.8 (3.70) 3.3 (1.96) 23.9 (4.48) 10.9 (2.83) 14.8 (3.81)

> 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 < 0.05 > 0.05 < 0.05 < 0.05 < 0.05 > 0.05 > 0.05

80.6 (3.74) 75.3 (3.53) 5.3 (2.48) 28.9 (4.42) 1.8 (1.68) 27.2 (4.17) 15.4 (3.09) a 13.4 (3.13) 119.7 (4.87) a,c 97.5 (9.11) 11.4 (2.68) a.c 5.2 (1.89) a 28.7 (2.45) c 22.0 (2.47) a,c 42.0 (3.50) 30.1 (2.59) a,c 117.4 (8.07) a.c 74.2 (4.03) 3.7 (1.83) 5.3 (1.13)

79.4 (4.47) 73.9 (4.00) 5.4 (3.05) 29.4 (4.65) 1.6 (1.03) 29.9 (3.36) b 20.5 (4.62) a,b 9.2 (5.48) 100.4 (8.30) a 97.8 (6.43) 3.5 (1.60) a 2.6 (1.38) a,b 30.6 (2.39) 24.2 (2.15) a 41.2 (3.08) 33.0 (2.20) a 125.2 (4.48) a 78.7 (3.04) 3.8 (2.25) 4.6 (2.24)

78.9 (2.94) 74.2 (2.53) 4.8 (3.02) 26.2 (6.57) 2.4 (1.25) 24.9 (6.36) b 14.3 (4.88) b 11.9 (6.35) 107.8 (9.60) c 97.2 (8.00) 5.8 (2.58) c 4.8 (1.75) b 31.8 (2.11) c 26.0 (2.02) c 43.6 (3.51) 34.0 (2.80) c 127.7 (5.48) c 83.8 (9.04) c 1.5 (2.71) 4.5 (2.24)

> 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 < 0.05

< 0.05 < 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05

114.1 (4.88) 110.6 (4.48) 98.5 (6.48) 101.9 (4.45) 8.6 (2.60) 4.2 (2.11) 6.9 (2.99) 3.3 (2.06) 30.3 (2.20) 24.2 (1.72) 41.8 (3.25) 32.5 (1.00) 79.7 (3.80) 0.7 (2.30) 2.1 (2.02)

< 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 < 0.05 < 0.05

> 0.05 > 0.05 > 0.05 > 0.05 > 0.05 > 0.05 < 0.05 > 0.05 > 0.05 < 0.05

U1perp/MxL 27.8 (2.75) U6perp/MxL 20.6 (2.83) LIperp/MnL L6perp/MnL N-Me S-Go UIperp/OL LIperp/OL 39.2 (3.19) 28.9 (1.75) 72.0 (6.09) 0.9 (2.90) 2.9 (1.64)

113.8 (4.28) 123.1 (2.77)

* Paired t - test Unpaired t - test The letters indicate groups significantly different at p < 0.05 with Duncans multiple range test

(U6perp/MxL), the lower molar dentoalveolar height (L6perp/MnL), anterior face height (AFH) and posterior face height (PFH). AFH and PFH increased by 9.3 mm and 7.7 mm respectively (Table II).

and 2.9 mm respectively. The AFH increased 7.9 mm during treatment. End of treatment Recall There were three significant differences between the end of treatment and recall stages: the Frankfort mandibular planes angle (FH/MnL) decreased 4.9 degrees; the occlusal plane maxillary plane angle (OL/MxL) decreased 6.2 degrees; overbite increased 2.1 mm. Initial Recall The inclination of the upper incisors to the maxillary plane (UI/MxL) remained significantly less at the recall stage in spite of a 7 degree relapse after treatment. By contrast, there were six significant linear differences. The mean overjet difference between the
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Treatment group
Initial End of treatment During treatment the upper incisors were tipped palatally (UI/MxL), and the occlusal plane maxillary plane angle (OL/MxL) increased significantly from 15.4 degrees to 20.5 degrees. There were five statistically significant differences between the linear measurements at the Initial and End stages (Table II). During treatment the overjet and overbite were reduced 7.9 mm and 2.6 mm respectively, and the perpendicular heights of the upper (U6perp/MxL) and lower (L6perp/MnL) molars increased 2.2 mm

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initial and recall stages was 5.6 mm. The upper incisor dentoalveolar height (UIperp/MxL) increased 3.1 mm, and the upper (U6perp/MxL) and lower molar (L6perp/MnL) dentoalveolar heights increased 4.0 mm and 3.9 mm respectively. The AFH increased 10.3 mm and the posterior face height (PFH) increased 9.6 mm.

at the start were similar. It would appear that orthodontic treatment may have no lasting effects on either the vertical height of the face or the vertical heights of the molars in girls with Class II division 1 malocclusion. This study was very small because of the difficulties we had finding patients that met the inclusion criteria, who could be located many years after their initial consultation and then persuaded to return for records. Because it was a small study it did not have much power to detect differences between the groups. The small numbers made it impossible for us to adjust for obvious differences, such as the length of follow-up. But in spite of the size of the study we did find some statistically significant differences at recall, which we will discuss below. The subjects were not randomly allocated to the groups at the outset so the possibility of some selection bias cannot be ruled out. In longitudinal cephalometric investigations it is essential to keep errors to a minimum so that they do not overwhelm the changes being measured. The main errors can arise from repositioning an individual in the cephalostat on different occasions, from combined errors of identification of the reference points and from the measurements made. Difficulties in identifying the landmarks are considered the source of greatest errors in cephalometric investigations. It was not possible to check the repositioning errors because the lateral cephalometric radiographs had been taken over a 12 year period by different people using two cephalostats. However, positioning errors are generally small in relation to the variation found between different individuals and the variation when the same individual is followed longitudinally. We investigated the errors in identification and measurement by remeasuring 10 randomly selected radiographs. We attributed two of the three significant differences to the difficulty we had in locating the reference points for the occlusal plane because the teeth concerned had large restorations.14 The third finding we attributed to a slight shift when constructing the planes to measure the height of the incisal edge of the upper incisor from the occlusal plane. All measurements were taken directly off the films without an intervening tracing. Where a reference point proved difficult to locate we used other radiographs belonging to the subject to aid identification of the point in question. This procedure probably reduced the error

Control vs Treatment
Initial stage The upper incisors in the treatment group were significantly more proclined, the overjet was significantly larger, the upper incisors (UIperp/OL) were significantly below the occlusal plane and the lower incisors (LIperp/OL) were significantly above the occlusal plane compared with the control group. Recall stage There were only two significant angular differences between the groups at this stage. Angles SNA and SNB were significantly smaller in the treatment group compared with the control group (Table II). The standard deviations in both angles at recall were less than those found initially. There were also two significant linear differences between the two groups: AFH was significantly greater in the treatment group, and the lower incisors were above the occlusal plane (LIperp/OL) to a greater extent than in the control group.

Discussion
We set out to determine if the increase in the height of the face that invariably occurs when the molars are extruded during orthodontic treatment, was permanent, or whether it was reversible.10 That is to say, the upper and lower molars and the mandible end up in the positions they would have occupied, had treatment not been carried out. We followed a group of 11 year-old girls with untreated Class II division 1 malocclusions for 8 years, and a similar-aged group of girls with treated Class II division 1 malocclusions for 12 years. After taking into account several differences at the outset, the age difference at the conclusion of the study (the treatment group were three years older than the control group) and the lesser amounts of variation at the conclusion of the study, it appears that the upper and lower molars and mandible ended up in the positions they would have occupied had treatment not been carried out. The ages of the girls
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variance within individuals, and as it was not used for all reference points systematic errors will be negligible. Elevation of the upper and lower molars during treatment was accompanied by a significant increase in anterior face height. Anterior face height was also significantly greater in the treatment group, as compared with the control group, at recall. Some might argue that this difference was evidence of an appliance-induced permanent increase in face height, but there were some notable differences between the groups at recall. Firstly, anterior face height was 3.5 mm longer (but not significantly so) in the treatment group at the start, secondly the treatment group was, on average, 3.5 years older than the control group at recall, and thirdly there was less variation within the groups at recall which would increase the probability of finding a significant difference between the two groups. In agreement with other studies the overbite was reduced during treatment, but relapsed after treatment.5,7,1517 Bearing in mind that anatomically stable landmarks could not be used, the increase in overbite appears to be due to continued vertical development of the upper and lower incisors relative to the occlusal and maxillary planes. The overbite reduced slightly, but not significantly so, in the control group. There was no significant difference in overbite between the two samples at recall. During treatment the upper incisors were retroclined 19 degrees and the overjet reduced 8 mm. Following treatment, however, the upper incisors proclined 7 degrees and the overjet increased 2.2 mm. Similar changes during and following treatment have been reported by others.1,6,15,16,1820 At the start of the study, both the overjet and the inclinations of the upper incisors to the maxillary plane were significantly larger in the treatment group than in the control group. Therefore, the absence of any statistically significant differences in either overjet or the inclination of the upper incisors at recall was unexpected, particularly as the upper incisors were retracted during treatment. A number of small changes in the angulations of both upper and lower incisors appear to have combined to produce these findings. Changes in the inclinations of both upper and lower incisors in the control group reduced the overjet approximately 2 mm, whereas the upper incisors relapsed 2.2 mm in the treatment group: in only one subject was the overjet less at recall than at

the end of treatment and in eight girls it relapsed. In view of these changes it is not surprising that there was no significant difference in overjet at the recall stage. In the control group the upper incisors retroclined 3.5 mm between initial and recall, and the lower incisors proclined about 3.5 mm. It has been reported that the upper incisors retroclined and the lower incisors proclined naturally in children with untreated Class II division 1 malocclusions.21,22 Several investigators have observed that in many adolescents lip posture changes from lips apart to lips together.23,24 It is postulated that as a lip seal developed labial to the upper incisors they would be retroclined by pressure from the lower lip, and the lower incisors would be free to procline because they would no longer be subjected to pressure from the lower lip. Although there was no significant difference between the SNA angles in the treatment and control groups at the start of the study, this angle was significantly smaller in the treatment group at recall. Palatal movement of point A, and slightly lesser variation in both groups at recall would account for this finding. Point A would be expected to move palatally in the six subjects who had their upper incisors torqued palatally.6,25 There was a small, but statistically significant difference in angle SNB at recall. This finding is less easily explained as the lower incisors were not torqued lingually in the treatment group, but the lesser variation in both groups at recall may account for this finding. During treatment, the lower molars were extruded slightly more than the upper molars (2.9 mm and 2.2 mm respectively) and the anterior end of the occlusal plane was tipped downwards 5 degrees. Following treatment however, the upper molars erupted more than the lower molars, 1.8 mm and 1.0 mm respectively. The vertical recovery of the molars after treatment lends support to the notion that each molar has a separate potential for vertical development/ eruption.26,27 Continued vertical development of the teeth and the alveolar process throughout life provides a mechanism for adjustment of molar heights after treatment.27,28

Conclusions
1. Orthodontic treatment may have no lasting effects on the vertical heights of the molars, incisors and faces of 11 year-old girls with Class II division 1 malocclusion.
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2. The increase in overbite post-treatment appeared to be due to continued vertical development of the upper incisors relative to the maxillary and occlusal planes and relapse of the lower incisors. 3. Altered lip posture in adolescence and altered soft tissue pressures on the teeth may be responsible for retroclination of the upper incisors in the untreated individuals, with a consequential reduction in the overjet.

Corresponding author
Dr Craig Sharp Private Bag MBE N330 Auckland New Zealand Tel: 00 64 9 524 9231 Fax: 00 64 9 520 0950 Email: csharp@ortho1.co.nz

References
1. Brodie AG, Downs WB, Goldstein A, Myer E. Cephalometric appraisal of orthodontic results. Angle Orthod 1938;8:261351. 2. Tovstein BC. Behaviour of the occlusal plane and related structures in the treatment of Class II malocclusions. Angle Orthod 1955;25:18998. 3. Hanes RA. Bony profile changes resulting from cervical traction compared with those resulting from intermaxillary elastics. Am J Orthod 1959;45:35364. 4. Ricketts RM. The influence of orthodontics on facial growth and development. Angle Orthod 1960;30:10333. 5. Bijlstra RJ. Vertical changes during Begg treatment. Trans Europ Orthod Soc 1969, p 38595. 6. Crytzer MR. Tooth movement with the Begg technique. Begg J Orthod Theory Treat 1969;5:8196. 7. Herzberg R. A cephalometric study of Class II relapse. Angle Orthod 1973;43:1128. 8. Menezes DM. Changes in tooth position and vertical dimension during Begg treatment. Brit J Orthod 1974;2:8591. 9. Reddy P, Kharbanda OP, Duggal R, Parkash H. Skeletal and dental changes with nonextraction Begg mechanotherapy in patients with Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop 2000;118:6418. 10. Melsen B. Effects of cervical anchorage during and after treatment: An implant study. Am J Orthod 1978;73: 52640.

11. Fidler BC, Artun J, Joondeph DR, Little RM. Long-term stability of Class II, Division 1 malocclusions with sucessful occlusal results at end of active treatment. Am J Orthod Dentofacial Orthop 1995;107:27685. 12. British Standards Institution 1983 BS4492, British Standard Glossary of Terms relating to Dentistry. London: British Standards Institution, 1983. 13. Dahlberg G. Statistical methods for medical and biological students. New York; Interscience: 1940:905. 14. Baumrind S, Frantz RC. The reliability of headfilm measurements. I. Landmark identification. Am J Orthod 1971; 60:11127. 15. Bennett TG, Tulloch JFC, Vig KWL, Webb WG. Overjet stability after treatment of Class II division 1 malocclusions. Brit J Orthod 1974;2:23946. 16. Bresonis WL, Grewe JM. Treatment and post-treatment changes in orthodontic cases: overbite and overjet. Angle Orthod 1974;44:2959. 17. Wood CM. The effect of retention on the relapse of Class II Division 1 cases. Brit J Orthod 1983;10:198202. 18. Huggins DG, Birch RH. A cephalometric investigation of upper incisors following their retraction. Am J Orthod 1964;50:8526. 19. Banks PA. An analysis of complete and incomplete overbite in Class II division 1 malocclusions (an analysis of overbite incompleteness). Brit J Orthod 1986;13:2331. 20. Looi LK, Mills JRE. The effect of two contrasting forms of orthodontic treatment on the facial profile. Am J Orthod 1986;89:50717. 21. Schaeffer A. Behaviour of the axis of human incisor teeth during growth. Angle Orthod 1949;19:25475. 22. Bjork A. Variability and age changes in overjet and overbite. Am J Orthod 1953;39:779800. 23. Ballard CF. Conclusions resumees actualles de lauteur relatives au comportement musculaire. CR Soc Franc dOrthopedie 1960;31:51324. 24. Walther DP. Some causes and effects of malocclusion. Dent Practit 1960;10:13954. 25. Holdaway RA. Changes in the relationship of points A and B during orthodontic treatment. Am J orthod 1956;42: 17693. 26. Murphy T. Compensatory mechanisms in facial height adjustment to functional tooth attrition. Aust Dent J 1959; 4:31223. 27. Ainamo J, Talari A. Eruptive movement of the teeth in human adults. In: The eruption and occlusion of teeth. Eds. Poole DFG, Stack MV. Colston papers No. 27. Butterworths, London. 1976, 97107. 28. Behrents RG. Growth in the aging craniofacial skeleton. Monograph 17, Craniofacial Growth Series, Center for Human Growth and Development, The University of Michigan. Ann Arbor: Michigan, 1985;99128.

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The relationships between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature
Jan van Gastel, * Marc Quirynen, Wim Teughels, Carine Carels *
Department of Orthodontics* and Department of Periodontology, Catholic University Leuven, Belgium

Aims: To review the literature on the periodontal implications of malocclusion and fixed orthodontic appliances. Methods: The PubMed database was searched for original articles on orthodontics and gingivitis/periodontology/plaque/ microbiology/histology, bracket and gingivitis/periodontology/plaque/microbiology/histology, crowding/spacing/overbite/overjet/open bite/crossbite traumatic occlusion and gingivitis/periodontology/plaque/microbiology/histology. Only articles published between 1970 and 30 April 2007 were used. The search was augmented by screening the references cited in each paper for additional articles that might have been missed by the electronic search. Results/Conclusions: Dental plaque is the primary cause of gingival inflammation and periodontitis. Conditions that encourage the growth and retention of dental plaque result in a localised gingivitis, which rarely progresses to periodontal disease. Only a few studies report attachment loss during orthodontic treatment. The contradictory findings on the impact of malocclusion and orthodontic appliances on periodontal health may be partly due to the selection of materials and differences in the research methods employed. (Aust Orthod J 2007; 23: 121129)
Received for publication: September 2007 Accepted: November 2007

Introduction
The number of patients undergoing orthodontic treatment with fixed appliances has increased steadily in recent decades.1 The majority of patients have been treated to improve their dentofacial aesthetics, and only a minority have required treatment for medical or dental reasons. Several indices, such as the Index of Orthodontic Treatment Need, have been developed to objectively score orthodontic treatment need, but no malocclusion index has a periodontal component.2 While crowded teeth are unsightly and frequently used to justify orthodontic treatment, they are also difficult to clean and might act as sites for the accumulation of dental plaque. The aetiology and pathogenesis of periodontal diseases are known to be multifactorial, but dental plaque, not malocclusion, is the essential precursor.3,4 It could be argued that as orthodontic appliances, particularly the brackets and bands, promote the accumulation of plaque and make tooth cleaning
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more difficult, they increase the risk of developing localised periodontal disease. The aims of this paper are to review the published literature on the periodontal consequences of malocclusion and those parts of fixed orthodontic appliances (brackets and bands) that retain dental plaque in proximity to the periodontal tissues. A description of the impact of orthodontic treatment on the periodontium, both short- and long-term, is included.

Material and methods


The PubMed database was searched for original articles on: orthodontics and gingivitis/periodontology/ plaque/microbiology/histology, bracket and gingivitis/periodontology/plaque/microbiology/histology, crowding/spacing/overbite/overjet/open bite/crossbite/traumatic occlusion and gingivitis/periodontology/plaque/microbiology/histology. Only articles published between 1970 and 30 April 2007 were used.
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The titles and abstracts of all potentially relevant articles were first reviewed. The full text versions of all relevant articles, articles with ambiguous titles and abstracts were then purchased and reviewed. The search was augmented by screening the references cited in each paper for additional articles that might have been missed by the electronic search.

Results Pathogenesis
Dental plaque Dental plaque is a complex biofilm that provides nutrients and protection for periodontopathic bacteria.5 It is the primary cause of gingival inflammation and periodontitis.6 The Gram-positive and mostly aerobic micro-organisms that initially colonise intra-oral hard surfaces are replaced by predominantly Gram-negative and anaerobic micro-organisms.7,8 T. forsythia, P. gingivalis, A. Actinomycetemcomitans and P. intermedia are found more frequently in patients with gingivitis and periodontitis than in healthy subjects. The quantity and the quality of dental plaque are important factors in the onset of periodontitis. Many factors, such as the characteristics of intra-oral hard surfaces (surface roughness, surface free energy),911 have been found to be positively correlated with the rate of growth of dental plaque.12 The presence of gingival inflammation will also promote the growth of plaque.13,14 Host reaction In 1976 Loesche15 postulated his specific plaque hypothesis and stated that certain micro-organisms in the dental plaque were pathogenic, and that overgrowth of these species would result in increased gingival inflammation due to the hosts immune response. The transition from a reversible gingivitis to an irreversible periodontitis is probably regulated by the bacteria-host reaction. Fransson et al.16,17 examined the host reaction to dental plaque in gingival specimens taken from young and old individuals, and reported that in the older subjects inflammation was more marked and there was a higher density of B-cells. They postulated that these differences were due to the different experiences of the young and old to microbial challenges.16,17
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Family studies suggest that environmental factors (e.g. oral hygiene and smoking) are major determinants of variance in adult periodontitis.18 Data from twin studies indicate that about half the population variance in periodontitis can be attributed to genetic factors.1925 Moreover, there is mounting evidence that genetic variations in or near the cytokine genes may influence the inflammatory response in individuals with periodontitis.2628

Intra-arch orthodontic anomalies


Arch-length discrepancies Despite the fact that relationships between arch length discrepancies and periodontal health have been studied frequently, there is little evidence that malocclusion and/or irregularity of the teeth affect gingival health. While it seems logical that removal of dental plaque is more difficult in crowded dentitions and that this might impact on periodontal health, modern concepts of periodontal health now emphasise the significance of the biologic, systemic and pro-inflammatory mediators in the development of periodontitis.29 In teenagers a low, but statistically significant, correlation was found between tooth irregularity (tilting, rotation, displacement, crowding) and the plaque and gingival inflammation scores.30 Tooth irregularity was less important than the extent of the plaque and calculus deposits.30 Ashley et al.31 also provided some support for the concept of an association between incisor irregularity and gingivitis. They reported a stronger association occurred when a labio-lingually displaced incisor was overlapped by an adjacent tooth than when it was not overlapped by an adjacent tooth. In spite of this finding the level of oral hygiene seemed to be the most important factor.31 It would appear that irregular teeth are more difficult to clean and, therefore, more likely to develop gingivitis. In his study of army recruits Ainamo32 reported that periodontal disease was more marked adjacent to malaligned maxillary anterior teeth and less marked in the premolar areas. He concluded that there were no associations between malaligned teeth and periodontal disease at extremes of oral hygiene.32 But Ingervall,33 who conducted a study of dental students with perfect oral hygiene who had refrained from interdental cleaning for 40 days, reported there was an equal increase in gingivitis in both the crowded

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and non-crowded dentitions. He disagreed with Ainamos conclusion that in individuals with average oral hygiene (brushing three times a day and no interdental cleaning) a crowded dentition did not enhance the accumulation of dental plaque and the development of gingivitis. Ngom et al.34 recently reported varying degrees of correlation between intra-arch relationships and periodontal health. The plaque and gingivitis indices were significantly correlated with crowding and displaced lower anterior teeth. Crowding in the lower dental arch was the only parameter that was significantly correlated with the severity of periodontal disease. A trend towards more favourable periodontal conditions in young subjects with a spaced dentition31,3436 has also been reported, but the findings were not statistically significant. Other researchers have reported significant associations between the number of open contacts and gingival health in children.31,36 It is interesting to note that there was no evidence of a similar relationship in adults.37,38 Alhaija and Al-Wahadni39 recently investigated associations between mild crowding and periodontal disease in individuals with good oral hygiene. The average number of sites with labio-lingually displaced teeth overlapped or not overlapped by adjacent teeth was 1.81 + 1.30 and 1.39 + 1.10 respectively. They found no significant associations between crowding and periodontal disease in subjects with good oral hygiene. Their findings in subjects with good oral hygiene were supported by Ashley et al.31 However, Ashley et al. found significant associations between irregularity and gingivitis in subjects with moderate and poor oral hygiene,31 which disagrees with Ainamos32 suggestion that when the oral hygiene was poor or non-existent, an association between crowding and gingivitis is less likely to be found. Staufer and Landmesser40 investigated the risk of individuals with different types of anterior crowding developing periodontal disease, and whether the risk was associated with the severity of crowding. They reported there was a greater risk of chronic gingival inflammation in the anterior region in older individuals when the crowding exceeded the threshold value of 3 mm. Mouth-breathing can also be a cofactor in the development of gingivitis in crowded dentitions. Jacobson and Linder-Aronson41 reported that mouth breathers

with crowding were more likely to develop gingivitis than nose breathers with crowded dentitions.

Inter-arch orthodontic anomalies


Open bite Open bites and incompetent lips may lead to the development of a localised gingival recession around the upper incisors. In their study of 101 subjects who had not received orthodontic treatment Ngom et al.34 reported that open bites were significantly, and positively, correlated with the plaque and gingivitis scores, the gingival bleeding index, loss of clinical attachment and pocket depth.34 Machtei et al.42 compared the lengths of the clinical crowns, the amount of gingival recession, oral habits and the periodontal indices in children with untreated anterior open bites with a matched control group. Although the plaque indices in the two groups were similar the open-bite group had significantly longer clinical crowns and more gingival inflammation. This may be due to the greater virulence of dehydrated plaque. It has been suggested that a localised gingival recession may develop around the upper incisors in young children with an open bite and incompetent lips.41,42 Crossbite Excessive forces are exerted in centric relation and maximal occlusion on teeth in crossbite, especially when a forced bite is present. Ngom et al.34 reported a significant correlation between a crossbite and gingival recession,34 which may be due to primary occlusal trauma. In centric relation and at the end of the closing phase during mastication, a tooth in crossbite may contact an opposing tooth prematurely. When this occurs the occlusal loads on the tooth in crossbite are unfavourable and may lead to gingival recession. While some researchers have reported higher periodontal scores in cases with crossbites, other researchers did not find any significant associations between crossbites and periodontal parameters.44 Occlusal trauma Although the influence of occlusal interferences on the health of the periodontium has been studied extensively, the evidence that occlusal interferences either initiate periodontal break-down or contribute to the progression of periodontal disease is inconclusive.4547 Some researchers consider that
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occlusal interferences/trauma are not a cause of periodontal disease,48 but they may contribute to the progression of the disease.47 Using evidence from an animal study Lindhe and Ericsson48 argued that occlusal trauma played a role in the progression of periodontal disease. Indirect evidence from a randomised clinical trial of patients with periodontitis also suggested that occlusal trauma may contribute to the break-down of the periodontal tissues.49 Bugett et al. reported a significant gain in attachment in patients with periodontitis who received conventional periodontal therapy and occlusal adjustment compared with those who received conventional therapy but no occlusal adjustment.49 These findings do not justify prophylactic adjustment of the occlusion with orthodontic treatment to prevent periodontal disease. However, occlusal interferences may be a significant risk factor in the progression of existing periodontal disease, and removal of occlusal interferences/trauma may significantly improve the outcome achieved with periodontal treatment.49 In healthy mouths occlusal trauma does not result in periodontal breakdown. Overjet Higher plaque scores and less alveolar bone have been found in individuals with an increased overjet. In a study of 19 year-old male military recruits Brojnaas et al.50 compared recruits with overjets >8 mm with recruits with nearly ideal occlusions. They reported that the alveolar bone height was 1 mm less in the upper incisor region and 0.4 mm less in the lower incisor region in the overjet group compared with the control group.50 In a large, longitudinal study of 12 year-old Welsh children Davies et al.51 reported a significant association between the mean plaque score, bleeding on probing and anterior overjet.51 They reported that plaque accumulation and gingivitis occurred at the extremes of overjet, both positive and negative. Other researchers have reported similar results; significantly higher plaque scores were found in subjects with increased overjets.34 Buckleys30 failure to find a significant correlation between overjet and the plaque and gingival indices would appear to contradict these findings. However, Buckleys study is not directly comparable to the studies reported by Brojnaas and Davies:30,50,51 Buckley used three groups and his large overjet group had individuals with overjets only >3 mm.

Overbite Increased overbite can result in the lower incisors impinging on the palatal mucosa or upper incisors impinging on the lower labial mucosa. Both conditions can result in recession and when this occurs orthodontic treatment is indicated.52 In less severe cases with no soft tissue damage, treatment may not be required. Bjornaas et al.50 demonstrated a significant reduction in alveolar bone heights in the upper (0.7 mm) and lower (0.5 mm) incisor regions in army recruits with overbites >5 mm compared with agepeers with an nearly ideal occlusions.50 Ngom et al.34 also reported significant positive correlations between increased overbite and attachment loss and pocket depth, but found no significant correlations between overbite and oral hygiene parameters. On the other hand, Buckley30 did not find any relationship between overbite and periodontal health.

Orthodontic treatment
The amount of dental plaque increases when orthodontic brackets, bands and fixed appliances are placed.5358 Most patients, even those with good oral hygiene, develop a generalised gingivitis following appliance placement, but usually there is no loss of attachment. Some studies have, however, reported loss of attachment during orthodontic treatment with fixed appliances.5961 Reliable indicators of early inflammation are the crevicular fluid flow (l/min) and the composition of cytokines in this fluid.62 Several techniques for the collection of crevicular fluid have been described.62 Cytokines, which mediate the host immunological response to exogenous antigens, are also produced by connective tissue cells such as fibroblasts and osteoblasts and are involved in normal physiological turnover and bone remodelling. Cytokines are low molecular weight proteins (< 25 kDa) produced by cells that regulate or modify the action of other cells in an autocrine (acting on the cell of origin) or paracrine (acting on adjacent cells) manner. The definition includes the interleukins (ILs), tumour necrosis factors (TNFs), interferons, growth factors, and colony stimulating factors. A major difficulty in understanding cytokine biology is the sheer number and complexity of these factors. Another problem is that several factors such as IL-1 and TNF exhibit overlapping biological activities (redundancy) and many have multiple biological effects

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pleiotropy). In clinical studies it may be difficult to distinguish between cytokine responses to inflammation and tooth movement during orthodontic treatment. A clinical manifestation of the inflammatory reaction is the increase in pocket depth caused by gingival hypertrophy (pseudo-pocket formation). Various explanations for this reaction in orthodontic patients with fixed appliances have been suggested in the literature: allergic reactions, mechanical irritation, cytotoxic effects of the band/bracket or bonding material and changes in (subgingival) microbiology. Comparisons of orthodontically treated and untreated groups have revealed some interesting findings. In a longitudinal study Sadowsky et al.63 compared subjects who had received orthodontic treatment during adolescence with a matched group of subjects with malocclusions that had not been treated. The groups were matched for race, sex, age, socio-economic status, oral hygiene and dental awareness. Although the general prevalence of periodontal disease in the groups was similar, a detailed analysis of the groups disclosed that the orthodontically treated group had mild to moderate periodontal disease in the upper posterior and lower anterior regions. While orthodontic treatment in adolescence is not an important determinant of periodontal health in the longterm, some unfavourable periodontal changes may be found in orthodontic patients in adulthood. Further research is needed to elucidate whether these changes are due the type or duration of the orthodontic treatment. Conversely, lack of orthodontic treatment in adolescence does not appear to influence the development of periodontal disease in adult life.63,64 A significant improvement in oral hygiene may follow orthodontic treatment. Davies et al.65 recorded plaque indices, bleeding indices, and the degree of dental irregularity of the anterior teeth in orthodontically treated and untreated children. The children were re-examined three years after the baseline examination. They reported significant reductions in the plaque and gingivitis scores on all tooth surfaces in both groups at the 3-year examinations. The children who had received orthodontic treatment had greater reductions, but these appeared to be due to behavioural factors rather than to improved tooth alignment.

Microbiology
Orthodontic appliances create a favourable environment for the accumulation of microbiota and food residues, which may cause caries or periodontal disease. Naranjo et al.58 observed a change in the microorganisms populating the subgingival dental plaque after the placement of brackets. The plaque gingivitis scores increased significantly. Levels of P. gingivalis, P. intermedia/P. nigrescens, T. forsythia, and Fusobacterium species were significantly elevated after bracket placement as compared with the untreated control group. Super-infecting micro-organisms such as E. cloacae, K. oxytoca, K. pneumoniae, and S. marcescens were also found in the treatment group.58 Lee et al.66 succeeded in detecting significant differences in the subgingival dental plaque retrieved from areas of gingivitis in patients with and without fixed appliances: T. forsythia, T. denticola, and P. nigrescens were more common in the orthodontic patients than in the control patients.66 These results indicate that following placement of fixed appliances, the pathogenic microorganisms in the dental plaque increased with a consequential increase in gingivitis. No differences in periodontal pocket depth were found. Changes in the types of micro-organisms were restricted to the dental plaque on the teeth supporting the orthodontic appliance.58,66 Local changes occur in the microbiota and periodontal tissues following placement of an orthodontic appliance. Huser et al.67 carried out clinical and bacteriological examinations at the beginning of orthodontic treatment and up to 90 days after placement of banded orthodontic appliances. They reported increased plaque and bleeding scores on the banded teeth as compared with the control sites. The probing depth, however, remained within normal values in the test and control groups. They also examined the composition of the dental plaque with dark-field microscopy, and found increased percentages of spirochetes, motile rods, filaments, and fusiforms at the test sites after banding. Over the 90 days there were no significant changes in the distributions of micro-organisms in the control group.67 In two small groups of banded and control patients DiamantiKipioti et al.68 observed an increase in black pigmented bacteria without an increase in the gingival and plaque indices. The mean pocket depths increased significantly from baseline levels in the experimental group, but not the control group.68 In a
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similar study Petti et al.69 compared the influence of fixed and removable orthodontic appliances on the supra- and subgingival microflora. Their data indicate that while gingivitis and periodontitis did not occur in patients with good oral hygiene during the first six months of treatment, changes in the oral microbiota over time suggest that patients with fixed appliances risk developing gingivitis and periodontitis.69 The abovementioned studies show that changes in the microbial environment after the placement of fixed orthodontic appliances are accompanied by increased gingivitis. The effects of the different materials used in modern orthodontics on the mictobiota and periodontal health have not been studied thoroughly. Trkkakraman et al.70 investigated the influence of different methods of archwire ligation (steel ligatures versus elastomeric rings) on the intra-oral microbial flora and periodontal health. Although teeth ligated with elastomeric rings exhibited slightly higher numbers of micro-organisms than the teeth ligated with steel ligature wires, the differences were not statistically significant. There were no differences in the gingival index, plaque index or pocket depths of the bonded teeth. However, the gingivae around the teeth ligated with elastomeric rings were prone to bleeding.70 Van Gastel et al.,53 in a randomised clin-ical trial with split-mouth design, compared the growth of plaque, clinical periodontal parameters and the crevicular fluid flow on teeth bonded with two different bracket types with non-bonded control teeth. They showed a significantly higher number of aerobes as well as anaerobe colony forming units (CFU) on the bonded teeth compared to the nonbonded controls. There were also significant differences between the teeth bonded with the different brackets. Most important of all was the significant difference in the ratio CFU aerobe/CFU anaerobe because this indicates the pathogenicity of the dental plaque layer. They concluded that the design of an orthodontic bracket system can make the oral environment less favourable for the development of plaque.

cells.55 The dominant cell type in the first month was lymphocytes, but subsequently plasma cells dominated. The topography of the leukocytic infiltrate also differed: plasma cells were located more centrally in the connective tissue, while lymphocytes and PMNs were located more superficially, close to the epithelium. After band removal the inflamed gingival lesions gradually recovered, but acanthosis of the sulcular epithelium persisted in some areas. Diedrich et al.71 also described the histopathological picture of an established gingival lesion. It consisted of a detached and severely damaged epithelial attachment, subgingival plaque, massive leukocyte infiltration (mainly lymphocytes, PMNs and plasma cells) and loss of collagen fibres, resulting in destruction of the intra-papillary fibre apparatus. The transseptal fibres, the final protective barrier opposing microbial infiltration of the alveolar bone, were infiltrated to varying degrees by cells. The cellular infiltration was particularly marked interdentally because of the subgingival position of the band margins. At one of these sites the connective tissue attachment was severely damaged, resulting in apical migration of the pocket epithelium, leading to a transition from chronic gingivitis to an initial irreversible periodontal lesion.71 The cement gaps of the orthodontic bands were analysed and were widest at the cervical margins (average gaps of 0.28 mm). In 85 per cent of the band margins defects in the cement margins were colonised with loosely dispersed dental plaque.71

Conclusions/clinical implications
1. Dental plaque is the primary cause of gingival inflammation and periodontitis. Transition from a reversible gingivitis to an irreversible periodontitis is regulated by the bacteria-host reaction, which may be studied by analysis of the crevicular fluid. Conditions that encourage the growth and retention of dental plaque increase the risk of developing localised periodontal disease. The gingivitis that develops during orthodontic treatment,57,58,65,67,81 is not likely to develop into a periodontitis. Only a few studies report attachment loss during orthodontic treatment.5961 2. Crowding has no adverse effects on periodontal health in cases with excellent oral hygiene, but in cases with average oral hygiene,3133 crowding promotes the accumulation of dental plaque, which may

Histology
In a longitudinal study of gingival biopsies from the buccal sites opposite molars Zachrisson demonstrated that, shortly after the insertion of bands, the gingival connective tissue was infiltrated by inflammatory

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impact detrimentally on the health of the periodontium.3133,40,43 In the majority of cases with poor oral hygiene crowding has no effect on periodontal health.3133 It is difficult to determine when gingivitis due to crowding will progress to adult periodontis. 3. Orthodontic closure and restorative closure of a diastema are contraindicated because both can have negative effects on periodontal health, especially in adults in their third and fourth decades of life.31,3436,72 4. A localised gingival recession may develop around the upper incisors in children with an anterior open bite and incompetent lips, possibly because lip incompetence leads to dehydration of the plaque.41,42 A positive association has been found between an open bite, the plaque score and periodontal health.34,42 5. Crossbites have no detrimental impact on plaque scores and periodontal health.34,44 6. Occlusal trauma does not initiate periodontal breakdown, but it may play a role in the progression of periodontal disease.45,46,73 Removal of occlusal trauma may result in a significant gain in attachment in patients with periodontitis. 7. Orthodontic treatment of severe overjets (>7 mm) and overbites (>5 mm) may be justified from a periodontal point of view.34,50,51 Long-term studies are required to clarify the periodontal implications of an increased overjet and overbite. 8. Periodontal screening should be an essential part of the orthodontic diagnosis.74 Before any orthodontic treatment is started patients should have excellent oral hygiene and the periodontium should be healthy. Loss of attachment before orthodontic treatment is not a contraindication for orthodontic treatment in a healthy mouth.7580 9. The contradictory findings on the impact of malocclusion and orthodontic appliances on periodontal health may be due to the selection of material and to differences in the research methods employed.

Department of Orthodontics U.Z. St. Rafael Kapucijnenvoer 33 B-3000 Leuven Belgium Tel: +32 16 33 24 49 Fax: +32 16 33 24 13 Email: Johannes.vanGastel@med.KULeuven.ac.be Johannes.vanGastel@uz.KULeuven.ac.be

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Dr J.L. van Gastel Faculty of Medicine School of Dentistry, Oral Pathology and MaxilloFacial Surgery

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subjects during the course of experimental gingivitis. J Clin Periodontol 1999;26:45360. Haffajee AD, Socransky SS, Lindhe J, Kent RL, Okamoto H, Yoneyama T. Clinical risk indicators for periodontal attachment loss. J Clin Periodontol 1991;18:11725. Corey LA, Nance WE, Hofstede P, Schenkein HA. Selfreported periodontal disease in a Virginia twin population. J Periodontol 1993;64:12058. Michalowicz BS, Aeppli D, Virag JG, Klump DG, Hinrichs JE, Segal NL et al. Periodontal findings in adult twins. J Periodontol 1991;62:2939. Michalowicz BS. Genetic and inheritance considerations in periodontal disease. Curr Opin Periodontol 1993;1117. Michalowicz BS. Genetic and heritable risk factors in periodontal disease. J Periodontol 1994;65:(Suppl:)47988. Michalowicz BS. Genetic risk factors for the periodontal diseases. Compendium 1994;15:1036, 1038, 1040 passim Michalowicz BS, Wolff LF, Klump D, Hinrichs JE, Aeppli DM, Bouchard TJ et al. Periodontal bacteria in adult twins. J Periodontol 1999;70:26373. Michalowicz BS, Diehl SR, Gunsolley JC, Sparks BS, Brooks CN, Koertge TE et al. Evidence of a substantial genetic basis for risk of adult periodontitis. J Periodontol 2000;71: 1699707. Cullinan MP, Westerman B, Hamlet SM, Palmer JE, Faddy MJ, Lang NP et al. A longitudinal study of interleukin-1 gene polymorphisms and periodontal disease in a general adult population. J Clin Periodontol 2001;28:113744. Lopez NJ, Jara L, Valenzuela CY. Association of interleukin1 polymorphisms with periodontal disease. J Periodontol 2005;76:23443. Taylor JJ, Preshaw PM, Donaldson PT. Cytokine gene polymorphism and immunoregulation in periodontal disease. Periodontol 2000 2004;35:15882. Socransky SS, Haffajee AD. The bacterial etiology of destructive periodontal disease: current concepts. J Periodontol 1992;63:32231. Buckley LA. The relationships between malocclusion, gingival inflammation, plaque and calculus. J Periodontol 1981; 52:3540. Ashley FP, Usiskin LA, Wilson RF, Wagaiyu E. The relationship between irregularity of the incisor teeth, plaque, and gingivitis: a study in a group of schoolchildren aged 1114 years. Eur J Orthod 1998;20:6572. Ainamo J. Relationship between malalignment of the teeth and periodontal disease. Scand J Dent Res 1972;80:10410. Ingervall B, Jacobsson U, Nyman S. A clinical study of the relationship between crowding of teeth, plaque and gingival condition. J Clin Periodontol 1977;4:21422. Ngom PI, Diagne F, Benoist HM, Thiam F. Intra-arch and interarch relationships of the anterior teeth and periodontal conditions. Angle Orthod 2006;76:23642. Silness J, Roynstrand T. Effects on dental health of spacing of teeth in anterior segments. J Clin Periodontol 1984;11: 38798. Feldens EG, Kramer PF, Feldens CA, Ferreira SH. Distribution of plaque and gingivitis and associated factors in 3- to 5-year-old Brazilian children. J Dent Child 2006; 73:410. Artun J, Osterberg SK. Periodontal status of teeth facing extraction sites long-term after orthodontic treatment. J Periodontol 1987;58:2429. Jernberg GR, Bakdash MB, Keenan KM. Relationship between proximal tooth open contacts and periodontal disease. J Periodontol 1983;54:52933.

39. Abu Alhaija ES, Al-Wahadni AM. Relationship between tooth irregularity and periodontal disease in children with regular dental visits. J Clin Pediatr Dent 2006;30:2968. 40. Staufer K, Landmesser H. Effects of crowding in the lower anterior segment a risk evaluation depending upon the degree of crowding. J Orofac Orthop 2004;65:1325. 41. Jacobson L, Linder-Aronson S. Crowding and gingivitis: a comparison between mouthbreathers and nosebreathers. Scand J Dent Res 1972;80:5004. 42. Machtei EE, Zubery Y, Bimstein E, Becker A. Anterior open bite and gingival recession in children and adolescents. Int Dent J 1990;40:36973. 43. Silness J, Roynstrand T. Relationship between alignment conditions of teeth in anterior segments and dental health. J Clin Periodontol 1985;12:31220. 44. Geiger AM, Wasserman BH. Relationship of occlusion and periodontal disease. Part X. Relation of cross-bite to periodontal status. J Periodontol 1977;48:7859. 45. Shefter GJ, McFall WT, Jr. Occlusal relations and periodontal status in human adults. J Periodontol 1984;55:36874. 46. Pihlstrom BL, Anderson KA, Aeppli D, Schaffer EM. Association between signs of trauma from occlusion and periodontitis. J Periodontol 1986;57:16. 47. Waerhaug J. The infrabony pocket and its relationship to trauma from occlusion and subgingival plaque. J Periodontol 1979;50:35565. 48. Lindhe J, Ericsson I. The influence of trauma from occlusion on reduced but healthy periodontal tissues in dogs. J Clin Periodontol 1976;3:11022. 49. Burgett FG, Ramfjord SP, Nissle RR, Morrison EC, Charbeneau TD, Caffese RG et al. A randomized trial of occlusal adjustment in the treatment of periodontitis patients. J Clin Periodontol 1992;19:3817. 50. Bjornaas T, Rygh P, Boe OE. Severe overjet and overbite reduced alveolar bone height in 19-year-old men. Am J Orthod Dentofacial Orthop 1994;106:13945. 51. Davies TM, Shaw WC, Addy M, Dummer PM. The relationship of anterior overjet to plaque and gingivitis in children. Am J Orthod Dentofacial Orthop 1988;93:3039. 52. Zimmer B, Seifi-Shirvandeh N. Changes in gingival recession related to orthodontic treatment of traumatic deep bites in adults. J Orofac Orthop 2007;68:23244. 53. van Gastel JL, Quirynen M, Teughels W, Coucke W, Carels C. Influence of bracket design on microbial and periodontal parameters in vivo. J Clin Periodontol 2007;34:42331. 54. Kloehn JS, Pfeifer JS. The effect of orthodontic treatment on the periodontium. Angle Orthod 1974;44:12734. 55. Zachrisson S, Zachrisson BU. Gingival condition associated with orthodontic treatment. Angle Orthod 1972;42:2634. 56. Alexander SA. Effects of orthodontic attachments on the gingival health of permanent second molars. Am J Orthod Dentofacial Orthop 1991;100:33740. 57. Sallum EJ, Nouer DF, Klein MI, Gonalves RB, Machion L, Wilson Sallum A et. al. Clinical and microbiologic changes after removal of orthodontic appliances. Am J Orthod Dentofacial Orthop 2004;126:3636. 58. Naranjo AA, Trivio ML, Jaramillo A, Betancourth M, Botero JE. Changes in the subgingival microbiota and periodontal parameters before and 3 months after bracket placement. Am J Orthod Dentofacial Orthop 2006;130:275.e 1722. 59. Zachrisson BU, Alnaes L. Periodontal condition in orthodontically treated and untreated individuals. I. Loss of attachment, gingival pocket depth and clinical crown height. Angle Orthod 1973;43:40211.

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MALOCCLUSION, FIXED ORTHODONTIC APPLIANCES AND PERIODONTAL DISEASE

60. Zachrisson BU, Alnaes L. Periodontal condition in orthodontically treated and untreated individuals. II. Alveolar bone loss: radiographic findings. Angle Orthod 1974;44: 4855. 61. Zachrisson BU. Cause and prevention of injuries to teeth and supporting structures during orthodontic treatment. Am J Orthod 1976;69:285300. 62. Griffiths GS. Formation, collection and significance of gingival crevice fluid. Periodontol 2000 2003;31:3242. 63. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80: 15672. 64. Polson AM, Subtelny JD, Meitner SW, Polson AP, Sommers EW, Iker HP et al. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofacial Orthop 1988;93:518. 65. Davies TM, Shaw WC, Worthington HV, Addy M, Dummer P, Kingdon A. The effect of orthodontic treatment on plaque and gingivitis. Am J Orthod Dentofacial Orthop 1991;99: 15561. 66. Lee SM, Yoo SY, Kim HS, Kim KW, Yoon YJ, Lim SH et al. Prevalence of putative periodontopathogens in subgingival dental plaques from gingivitis lesions in Korean orthodontic patients. J Microbiol 2005;43:2605. 67. Huser MC, Baehni PC, Lang R. Effects of orthodontic bands on microbiologic and clinical parameters. Am J Orthod Dentofacial Orthop 1990;97:21318. 68. Diamanti-Kipioti A, Gusberti FA, Lang NP. Clinical and microbiological effects of fixed orthodontic appliances. J Clin Periodontol 1987;14:32633. 69. Petti S, Barbato E, Simonetti DArca A. Effect of orthodontic therapy with fixed and removable appliances on oral microbiota: a six-month longitudinal study. New Microbiol 1997;20:5562. 70. Trkkahraman H, Sayin MO, Bozkurt FY, Yetkin Z, Kaya S, Onal S. Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients. Angle Orthod 2005;75:2316.

71. Diedrich P, Rudzki-Janson I, Wehrbein H, Fritz U. Effects of orthodontic bands on marginal periodontal tissues. A histologic study on two human specimens. J Orofac Orthop 2001;62:14656. 72. Broadbent JM, Williams KB, Thomson WM, Williams SM. Dental restorations: a risk factor for periodontal attachment loss? J Clin Periodontol 2006;33:80310. 73. Lindhe J, Ericsson I. The influence of trauma from occlusion on reduced but healthy periodontal tissues in dogs. J Clin Periodontol 1976;3:11022. 74. Turpin DL. Periodontal screening: a basic part of the orthodontic examination. Angle Orthod 1994;64:1634. 75. Kokich VG. Adult orthodontics in the 21st century: guidelines for achieving successful results. World J Orthod 2005;6 Suppl:1423. 76. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3:2138. 77. Melsen B. Orthodontic treatment of patients with periodontal lesions. J Parodontol 1987;6:28596. 78. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:10416. 79. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989;96:23241. 80. Williams S, Melsen B, Agerbaek N, Asboe V. The orthodontic treatment of malocclusion in patients with previous periodontal disease. Br J Orthod 1982;9:17884. 81. Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthod 1979;76:27786.

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Treatment of a Class I deep bite malocclusion in a periodontally compromised adult


Marcelo do Amaral Ferreira and Rogrio do Amaral Ferreira
Private practice, Curitiba, Paran, Brazil

Background: Light forces and an appropriate force system should be used to treat adult patients with periodontal disease. Aims: To describe the orthodontic treatment of an adult patient with a Class I deep bite malocclusion, horizontal and vertical bone loss and root resorption. Methods: After periodontal surgery and initial alignment of the maxillary incisors with a fixed orthodontic appliance the maxillary incisors were splinted together as a single unit. A double palatal arch and sectional buccal archwires were used for anchorage. The palatal arch and splint were joined by a NiTi coil spring (100 g). The incisor segment was then intruded and retracted with a force acting just below the centre of resistance of the splinted incisor teeth. The force system avoided extruding the maxillary molars. The maxillary teeth were then rebonded to close the spaces between maxillary lateral incisors and canines. A Hawley appliance was used for retention. Treatment was completed in 22 months. Conclusions: Surgical treatment and intrusion with light forces encouraged the development of periodontal attachment to the teeth affected by severe horizontal and vertical bone loss. Retraction of the proclined incisors improved the facial aesthetics. (Aust Orthod J 2007; 23: 130136)
Received for publication: May 2006 Accepted: August 2007

Introduction
Many adult patients will agree to orthodontic treatment when the benefits, such as improved facial aesthetics and the preservation of periodontally compromised teeth, are explained to them.1,2 Patients with active periodontal disease threatening the longevity of their dentitions are often unaware of this fact, despite the appearance of spaces between teeth that were previously in contact and/or previously well-aligned incisors that have become flared and protrusive.2 The first step in the management of these complex clinical problems is to ensure that the patient understands the importance of the procedures prior to orthodontic treatment. These generally involve improved oral hygiene, better diet and extensive periodontal treatment, often involving flap surgery. Because treatment for these cases has certain risks and limitations, such as loss of teeth and incomplete treatment, patients should give their informed consent before any orthodontic treatment is undertaken. For his part the orthodontist should use light forces, and a force system capable of completing the
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desired treatment with the minimal damage to an already compromised periodontal attachment.3,4 In this report we describe a case with vertical and horizontal bony defects in both arches. A successful outcome for this patient depended on the establishment of a comprehensive treatment plan, and extensive periodontal treatment before orthodontic treatment to retract procumbent incisors could be undertaken.5

Case report
A 47 year-old male Caucasian asked for an orthodontic evaluation. He had noticed that his previously well-aligned maxillary incisors had become spaced and protrusive. Apart from this observation he was unaware of the health of his teeth and their supporting tissues. He was mesofacial and had a symmetrical face with a mildly convex profile (Figure 1). The maxillary incisors and lower lips were protrusive.

Dental analysis
The patient had a bilateral Class I molar relationship, with flared and procumbent maxillary incisors, an
Australian Society of Orthodontists Inc. 2007

TREATMENT OF A DEEP BITE MALOCCLUSION IN A PERIODONTALLY COMPROMISED ADULT

Figure 1. Pretreatment profile and frontal photographs.

Figure 2. Pretreatment intra-oral photographs.

overjet of 8 mm and an overbite of 5 mm. The mandibular incisors impinged on the palatal mucosa. Although the maxillary dental midline was coincident with the facial midline, the mandibular midline was 2 mm to the right side of the maxillary midline (Figure 2). The lower arch was constricted with the right second premolar inclined lingually. The curve of Spee was increased, and there was 3 mm of crowding in the mandibular arch. The Bolton analysis suggested a slight tooth size discrepancy in the mandibular anterior region. The patient had no temporomandibular symptoms and there were no clinical signs of temporomandibular joint dysfunction. There was no history of bruxing or parafunctional activity.

Radiographic evaluation
The pretreatment panoramic film confirmed that all permanent teeth, except the third molars, were present. It also confirmed that the maxillary right lateral and central incisors, the maxillary right second premolar and mandibular right lateral incisor were root filled (Figure 3). There were vertical and horizontal bony defects in both arches, particularly involving the maxillary right lateral and central incisors. Bone had been lost along more than half the mesial and distal root surfaces of these teeth. There was also evidence of external root resorption involving the maxillary central and lateral incisors. The mandibular condyles appeared to be asymmetrical.
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Figure 3. Pretreatment panoramic radiograph.

Figure 4. Pretreatment cephalometric radiograph.

Figure 5. Estimated centre of resistance for lateral and central incisors. The open circle indicates the estimated centre of resistance for maxillary lateral and central incisors.

Periapical views confirmed the extensive bone loss and external resorption. The lateral cephalogram confirmed that the patient had a skeletal 1 relationship, protruding maxillary incisors and proclined lower central incisors (Table I, Figure 4).

Problem list
The principal problems were: generalised severe chronic periodontitis with horizontal and vertical bone loss, particularly on the maxillary incisors; external root resorption involving the maxillary right incisors; proclined maxillary incisors with an 8 mm overjet and severe lip strain on closure; the mandibular incisors impinged on the palatal mucosa.
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The first objective was to improve the patients periodontal health by improving his oral hygiene, by deep scaling and root planing, and periodontal surgery of the teeth with deep pockets. When this objective had been met the intention was to align the teeth in both arches, to reduce the overbite and overjet by intruding and retracting the maxillary anterior teeth with a force acting just below the combined centre of resistance of the incisors; to obtain facial balance with the lips in contact when at rest; to provide a stable and functional occlusion.

Treatment
Root scaling, planing and modified Widman flap surgery were used to correct the bony defects and remove

TREATMENT OF A DEEP BITE MALOCCLUSION IN A PERIODONTALLY COMPROMISED ADULT

Figure 6. Upper appliance. Double palatal arch, NiTi closed coil from palatal arch to splint, sectional buccal archwires.

debris and granulation tissue from the teeth with pockets. Ten days later the periodontal status was considered to be healthy and under control.3 After the treatment plan and risks had been explained to the patient, it was decided to band and bond both arches with a 0.022 x 0.028 inch preadjusted brackets and use 0.0175 inch multistrand archwires to align the teeth. The initial archwires were replaced
Table I. Summary of cephalometric findings.

one month later with 0.014 inch stainless steel archwires and then, at monthly intervals, 0.016 inch stainless steel and 0.016 x 0.016 inch NiTi archwires. When final alignment had been obtained, the incisor brackets were removed and impressions were taken for a modified splint plate to intrude and retract the maxillary incisors as a single unit, with the retraction force passing slightly below their combined centre of resistance (Figure 5).6 The objectives were to retract the upper incisors with minimal extrusion, and with little/no molar extrusion. The splint plate would ensure that the incisors acted as a single unit during retraction. A closed 100 g NiTi coil spring (GAC International, Japan) was stretched between a hook set into the acrylic splint section of the appliance and a hook on the palatal arch soldered to the upper first molar bands (Figure 6). Two sectional 0.016 x 0.022 inch stainless steel wires were placed buccally in the maxillary arch. A 0.017 x 0.025 inch stainless steel archwire was placed in the lower arch. After intrusion and retraction of the maxillary incisors, the incisor brackets were rebonded and a continuous 0.017 x 0.025 inch TMA archwire placed. Approximately, one month later this was followed by a 0.019 x 0.025 inch TMA wire. A hybrid archwire (0.019 x 0.025 inch TMA wire in the incisor segment and sectional

Area

Measurement

Standard

Pretreatment

Posttreatment

Difference

Maxilla to cranial base Mandible to cranial base

Maxillo-mandibular Maxillary dentition

Mandibular dentition

Interincisal relationship Occlusal plane Soft tissue Facial height index13

SNA () SNB () SN-Go-Gn () FMA () ANB () 1 to NA (mm) 1 to SN () 1 to NA () 1/FPI () Ballard 1 to NB (mm) 1 to NB () IMPA () 1/1 () Occ. Pl () Z angle () PFH (mm) AFH (mm) FHI

82 4 76 3 32 22 3 52 4 103 22 107 4 25 95 6 127 10 14 78 5 30 to 60 (41) 39 to 80 (60) 0.70

80 77 34 26 3 12 120 40 132 6 25 92 111 12 76 54 71 0.76

79 76 35 27 3 7 100 21 113 8 26 95 129 16 77 54 74 0.72

1 1 1 1 0 5 20 19 19 2 1 3 18 4 1 0 3 0.04

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Figure 7. Post-treatment profile and frontal photographs.

Figure 8. Post-treatment intra-oral photographs.

0.019 x 0.025 inch stainless steel wires in the buccal segments joined with 0.017 x 0.025 inch NiTi T-loops) was used to close the spaces between the maxillary lateral incisors and canines. No elastics were worn during treatment. The finishing archwires were 0.019 x 0.025 inch stainless steel. The appliance was removed and Hawley retainers placed in both arches. The maxillary Hawley appliance had canine hooks for light anterior elastics. The patient was referred to his dentist to determine if there was any need for occlusal adjustment after 22 months of active treatment. No occlusal adjustment was necessary. Post-treatment the right side molars were in an endto-end relationship and the canines in Class II relationship, which may have been avoided if the
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right second premolar had been extracted. This option was rejected because it considered space closure could result in the incisor extrusion and prolonged treatment. The left side molars and canines maintained a Class I relationship, and the midlines and bone levels improved significantly (Figures 7 to 9). The maxillary incisors were monitored with radiographs and no increase in root resorption was observed post-treatment. Root resorption in orthodontic patients has been associated with a number of systemic conditions, but in patients with chronic periodontal conditions it may occur in the absence of an orthodontic force.7,8 The post-treatment cephalometric tracing shows good control of the vertical occlusal plane (Table I, Figures 10 and 11). The skeletal relationship (angle

TREATMENT OF A DEEP BITE MALOCCLUSION IN A PERIODONTALLY COMPROMISED ADULT

Figure 9. Post-treatment panoramic radiograph.

Figure 10. Post-treatment cephalometric radiograph.

Figure 11. Pre- and post-treatment cephalometric superimpositions. Superimposition on S-N plane at sella (left), and area superimpositions on ANS-PNS at ANS and mandibular plane at menton (right).

ANB) was maintained, and the maxillary incisors were retroclined and extruded slightly. The mandibular incisors were proclined slightly and the mandibular molars distalised and slightly extruded. The maxillary molars were protracted bodily.

maxillary incisors pretreatment and periodontal surgery had been carried out, loss of the interdental papillae was expected. As a result, dark spaces were present between the anterior teeth at the end of treatment. One of the aims of the appliance used was to apply a light and predictable force (about 25 g to each incisor) from a 100 g NiTi coil spring stretched between the splint and palatal sections of the appliance. A second aim was to arrange the force vector slightly below the combined centre of resistance of the incisors so that the incisors would be tipped
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Discussion
The external root resorption, severe bone loss and procumbent incisors limited the treatment approach, which was chosen to minimise the risk of further attachment loss and root resorption. Due to the fact that there had been significant bone loss around the

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palatally. In the present case true palatal translation of the maxillary incisors may have reduced the overjet, but it would not have reduced the marked incisor proclination associated with the periodontal condition. A combined orthodontic-periodontal approach is essential for the successful management of adults with a malocclusion and severe horizontal and vertical bone loss.3 The first steps are to stabilise the patients periodontal condition with good home care and periodontal treatment. It is also necessary to obtain good compliance from the patient. Providing there is no further periodontal disease a new attachment may be formed after orthodontic intrusion. There is also some evidence that periodontal surgery produces a positive stimulus for new bone formation.3,911 The small decrease in the facial height index (from 76 degrees to 72 degrees) occurred because the vertical dimension increased slightly.12,13 We attribute this change to the small amount of mandibular molar extrusion as there was a corresponding increase in the occlusal plane to Frankfort plane angle. There were no adverse effects on the vertical positions of the maxillary incisors. After orthodontic treatment there were still significant bony defects and gingival margin discrepancies, especially in the maxillary anterior and posterior regions. The periodontal tissues appeared healthy, there was minimal apical root resorption and the roots of the teeth were in good positions. Favourable facial aesthetics were also achieved. Interdigitation of the teeth on the right side could have been better had the second premolars been extracted but, as we have mentioned above, this option was rejected to avoid prolonged treatment, possible loss of teeth and extrusion. However, a good functional result was obtained with group function in lateral excursions and anterior guidance with posterior disocclusion. The midline deviation was also corrected.

closed coil spring. Retraction of the proclined incisors improved the facial aesthetics.

Corresponding author
Dr Marcelo do Amaral Ferreira 1183, Pref. Omar Sabbag Avenue Jd. Botanico Zip Code 80.210.000 Curitiba, Paran Brazil Tel: +41 3262 2672 Email: marcelo.ferreira@avalon.sul.com.br

References
1. 2. Busson E. Contribution des Techniques Pluridisciplinaires a lEsthtique. Orthod Fr 1991;62:191249. Melsen B. Management of severely compromised orthodontic patients. In: Nanda R, ed. Biomechanics in clinical orthodontics. Philadelphia: WB Saunders, 1997: 294319. Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion of migrated incisors with infrabony defects in adult periodontal patients. Am J Orthod Dentofacial Orthop 2001;120: 6715. Burstone CJ. Deep overbite correction by intrusion. Am J Orthod 1977;72:122. Turley P. An American Board of Orthodontics case report: the surgical-orthodontic management of a Class I malocclusion with excessive overbite and periodontal bone loss. Am J Orthod Dentofacial Orthop 1993;104:40210. Vanden Bulcke MM, Burstone CJ, Sachdeva RCL, Dermaut LR. Location of centers of resistance for anterior teeth during retraction using the laser reflection centers technique. Am J Orthod Dentofacial Orthop 1987;91:37584. Davidovitch Z, Godwin S, Young-Guk P, Taverne AAR, Dobeck JM, DeSanctis GT. The etiology of root resorption. In: McNamara JA, Trotman CA, eds. Orthodontic treatment: Management of unfavorable sequelae. Ann Arbor: Center of human growth and development, University of Michigan 1996:93117. Owman-Moll P, Kurol J. Root resorption after orthodontic treatment in high- and low-risk patients: analysis of allergy as a possible predisposing factor. Eur J Orthod 2000;22: 65763. Roberts WE, Chase DC. Kinetics of cell proliferation and migration associated with orthodontically induced osteogenesis. J Dent Res 1981;60:17481. Nemcovsky CE, Beny L, Shanberger S, Feldman-Herman S, Vardimon A. Bone apposition in surgical bony defects following orthodontic movement: a comparative histomorphometric study between root and periodontal ligament-damaged and periodontally intact rat molars. J Periodontol 2004;75:101319. Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G. Orthodontic movement into infrabony defects in patients with advanced periodontal disease: a clinical and radiological study. J Periodontol 2003;74:11049. Vaden JL, Harris EF, Behrents RG. Adult versus adolescent Class II correction: a comparison. Am J Orthod Dentofacial Orthop 1995;107:65161. Horn AJ. Facial height index. Am J Orthod Dentofacial Orthop1992; 102:1806.

3.

4. 5.

6.

7.

8.

9.

10.

Summary
Pretreatment periodontal surgery and intrusion with light forces encouraged the development of a periodontal attachment to the teeth affected by severe horizontal and vertical bone loss. Following orthodontic alignment the maxillary incisors were splinted together and retracted with a force acting just below the combined centre of resistance of the maxillary incisors. Anchorage was provided by a palatal arch and sectional buccal archwires and retraction by a
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11.

12.

13.

Use of miniscrews as temporary anchorage devices in orthodontic practice. II - Case reports


George Anka
Specialist practice, Tama-shi, Tokyo, Japan
Aim: To illustrate the use of miniscrews to facilitate tooth movement mesially, distally and vertically. Method: Three cases are presented showing the use of miniscrews and direct and indirect forces. (Aust Orthod J 2007; 23: 137146)
Received for publication: March 2006 Accepted: September 2007

Introduction
Miniscrews, or temporary anchorage devices (TAD), have become increasingly popular because of their ability to provide stable anchorage and facilitate tooth movement, often in directions not possible with conventional methods. In a previous paper miniscrews were introduced and the direct and indirect application of forces from these devices described.1 The sites for miniscrews and some of their limitations were discussed. Although many cases require simultaneous tooth movement in several directions the following cases have been selected to illustrate the use of direct and indirect forces from miniscrews.

The treatment preference was to extract teeth 15, 25, 45 and the supernumerary tooth to provide space to correct the crowding in both arches. The wider first bicuspids would provide a better occlusion with the opposing teeth and offer more occlusal guidance than the smaller second bicuspids. Furthermore, should the extraction spaces open post-treatment they would be less visible and easier to close. Buccal miniscrews were placed in the mandible between the left second bicuspid and canine and the right first and second molars (Figure 3a). Buccal and palatal miniscrews were placed in the maxilla between the right and left first and second molars (Figures 3b and 3c). The sites for the miniscrews were determined by the location of the crowding and the midline discrepancies. As there were adequate spaces between the roots of the teeth the devices were inserted at the beginning of the treatment. However, in many cases miniscrews are placed after the teeth have been aligned. Composite onlays were added to the occlusal surfaces of the upper molars to prevent interference from the cusps of the bicuspids during retraction (Figure 3b).2 Lingual buttons were bonded to the palatal surfaces of the upper canines and first bicuspids and the teeth retracted with short lengths of elastomeric chain to the palatal miniscrews (Figures 3b and 3c). This is an example of a direct force.1 As treatment progressed the composite molar onlays were removed and composite pads bonded to the palatal surfaces of the upper central incisors (Figure 3c). The extraction spaces closed within 10 months and the midlines were corrected over the ensuing months. There were no detrimental changes in her profile (Figure 1).
Australian Orthodontic Journal Volume 23 No. 2 November 2007

Case reports Case 1. Extraction treatment use of direct force


A 35 year-old woman presented with the chief complaint of an unsightly upper left canine that had emerged high in the labial sulcus. She felt the prominence of the canine gave her an unattractive smile and had affected her self-esteem. The overjet and overbite were within normal limits and both upper and lower midlines had shifted to the left side. The second bicuspids and molars were restored. In the lower arch the bicuspids and left lateral incisor were crowded and a small, peg-shaped supernumerary tooth was impacted between the left canine and second bicuspid (Figures 1 and 2, Table I). The objectives were to reduce the prominence of tooth 23 and relieve the crowding in both jaws without a detrimental change in her profile, to correct the midlines and close any residual extraction spaces.
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ANKA

Table I. Cephalometric findings.

Case 1 35 y 6 m 37 y 9 m 15 y 4 m

Case 2 17 y 2 m 16 y 0 m

Case 3 18 y 4 m

Facial angle Convexity A-B plane Y-axis FH to SN SNA SNB ANB N-Pog to SN Nasal floor to SN Nasal floor to FH Mandibular plane to SN Mandibular plane to FH Ramus plane to SN Ramus plane to FH Gonial angle U1 to SN U1 to FH L1 to mandibular plane Interincisal angle Occlusal plane to SN Occlusal plane to FH

82.2 6.3 -3.2 66.3 7.8 77.4 75.0 2.4 74.4 15.3 7.4 40.5 32.6 98.9 91.0 121.6 93.6 101.5 88.4 137.5 24.9 17.1

86.5 7.4 -4.8 62.4 11.0 79.1 75.8 3.3 75.6 15.4 4.4 39.2 28.2 100.0 89.0 119.2 97.1 108.0 96.9 126.8 21.9 10.9

82.1 3.6 -0.7 67.7 9.0 75.0 73.9 1.1 73.1 9.6 0.6 49.1 40.1 95.8 86.9 133.2 110.9 119.9 78.4 121.6 22.7 13.7

85.7 3.4 -1.8 64.6 13.4 74.1 72.5 1.6 72.3 7.6 -5.8 49.9 36.5 91.1 77.7 138.8 101.0 114.5 85.7 123.4 24.9 11.5

85.6 -5.0 4.8 65.1 7.4 75.6 79.0 -3.4 78.2 10.3 2.9 39.7 32.4 103.7 96.3 116.1 106.8 114.1 90.0 122.6 20.9 13.5

86.0 -4.3 4.8 64.9 6.4 77.5 80.1 -2.6 79.6 7.5 1.1 38.5 32.1 93.4 87.0 125.1 110.4 116.8 77.6 133.6 16.9 10.5

Figure 1. Pre- and post-treatment profile views of Case 1.

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Figure 2. Pretreatment intra-oral photographs of Case 1.

(a)

(b)

(c)

Figure 3. (a) Buccal miniscrews between teeth 26, 27 and 33, 35 (reflected image). (b) Palatal miniscrews between teeth 16, 17 and 26, 27, elastomeric chains to lingual buttons and composite additions to the occlusal surfaces of the molars. Only the left buccal miniscrew is visible. (c) A later stage in treatment: palatal and buccal miniscrews and anterior biteplanes on teeth 11, 21.

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Figure 4. Post-treatment intra-oral photographs of Case 1.

Treatment was completed in 21 months, which in our experience is a slightly shorter period than conventional treatment would have taken (Figure 4). However, the miniscrews gave us greater freedom in the choice of the extraction sites, provided ample anchorage to complete the treatment and avoided use of any extra-oral device. Therefore, the success of treatment was not threatened by a failure to wear an extra-oral appliance.3,4 Although the miniscrews were removed at the time of debonding they may be left in place until the clinician is confident that relapse is unlikely.

an acceptable profile (Table I). The main objectives were to improve the positions of the upper anterior teeth, particularly tooth 11, and reduce the gummy smile. Extraction of bicuspids was considered and would have been the treatment choice prior to the introduction of miniscrews.57 In this case we decided not to extract bicuspids, but to distalise the teeth with the aid of miniscrews. All third molars were present. After consultation with the patient and her parents, the lower third molars were extracted and the remaining lower molars uprighted. A tongue frenectomy was also carried out, followed by myofunctional therapy. The patient and her parents would not agree to have the upper third molars extracted, which limited distalisation of the upper molars. In cases such as this retention of the upper third molars may be associated with relapse of the upper molars. After the extraction of the lower third molars, fixed appliances were placed to align and level the teeth in both jaws. Four months after bonding the appliances,

Case 2. Nonextraction treatment use of indirect force


A 15 year-old girl presented with a forward tongue posture and tongue thrust during swallowing, short tongue frenulum and bimaxillary protrusion. She was concerned about the positions of the upper anterior teeth and her gummy smile (Figure 5). The anterior teeth in both jaws were crowded, the overbite reduced and the overjet increased (Figure 6). She had
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Figure 5. Full face photographs of Case 2 at the start of treatment and post-treatment. Patient smiling.

Figure 6. Pretreatment intra-oral photographs of Case 2.

palatal miniscrews and an upper palatal arch bar were used to intrude the upper molars and increase the overbite (Figure 7). When the overjet and overbite were corrected we turned our attention to the gummy smile, and after consulting the patient we placed two further miniscrews between the upper central and lateral incisors (Figure 7b). Short Class III intra-oral elastics were used to improve the interdigitation and upright the lower incisors. To correct the upper midline the anterior section of the palatal arch was removed and the horizontal sections (extended arms) and elastomeric chain used to distalise the molar on one side without affecting the teeth on contralateral side (Figure 7c). Distalisation using an extended arm should be done carefully as the molar to which the arm is attached may rotate. When

the upper molars are displaced relative to each other an extended arm(s) should be used from the beginning of treatment. We have found that if the molars on one side have to be moved more than 23 mm, bilateral chain from buccal and palatal miniscrews will prevent the molar from rotating and ensure that it moves distally without binding. In the present case the appliance was removed after 17 months of treatment (Figure 8). The protrusive upper teeth and gummy smile were corrected and the tendency to an open bite reduced: the latter proved to be the most difficult part of the correction (Figures 5 and 8). During treatment the mandible rotated clockwise, in spite the small amount of molar intrusion evident on the cephalometric tracings (Figure 9, Table I). After treatment the patient was pleased
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(a)

(b)

(c) Figure 7. (a) Palatal arch with short chains to miniscrews. (b) Labial miniscrews covered with wax between teeth 11, 12 and 21, 22. (c) Extended palatal arms made from horizontal sections of the palatal arch, elastics not shown.

Figure 8. Post-treatment intra-oral photographs of Case 2.

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Figure 9. Cephalometric tracings of Case 2.

(a) Figure 10. Pre- and post-treatment profile views of Case 3.

(b)

with her profile and ability to eat foods that she had previously found difficult to incise.

Case 3. Nonextraction, skeletal 3 open bite correction indirect force


A mild skeletal jaw discrepancy may be camouflaged by repositioning the teeth so that a favourable result, both functionally and aesthetically, is obtained. As the skeletal discrepancy worsens orthodontic treatment alone cannot meet these objectives and orthog-

nathic surgery is the preferred choice of treatment. Skeletal malocclusions with a vertical component, such as an anterior open bite, are especially difficult to treat with conventional orthodontic methods.8.9 The following case demonstrates the value of miniscrews for treatment of a skeletal 3 open bite malocclusion after earlier orthodontic treatment had failed. Class II open bite malocclusions can also be treated successfully with the aid of miniscrews and extraction of bicuspids.10

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(a)

(b)

(c)

Figure 11. Pretreatment intra-oral photographs of Case 3.

(a)

(b)

Figure 12. Side and palatal views of the appliances. The posterior maxillary teeth have been intruded and distalised slightly.

This 16 year-old boy presented with a skeletal 3 malocclusion with an anterior open bite. His chief complaint was of an anterior crossbite. He had had orthodontic treatment before, but the appliance had been removed because of poor hygiene and lack of cooperation. The patient had passed the peak adolescent growth spurt in height. He had a Class III profile and a protrusive lower lip (Figure 10a). He also had an anterior open bite and the upper central incisors and left lateral incisor were in crossbite (Figure 11). The patients chin and the lower midline were displaced to his left side. The latter was 3 mm to his left side (Figure 11b). The mandible was not displaced on closure into the intercuspal position. The cephalometric findings indicated that he had a moderate skeletal 3 malocclusion (Table I). The primary objectives were to correct the anterior open bite and anterior crossbite. The treatment

options discussed with the patient and his parents were orthodontic treatment and orthognathic surgery. The latter was considered should further facial growth worsen either the open bite or anterior crossbite.9 The treatment preference was for nonextraction orthodontic treatment with miniscrews to retract the lower molars as much as possible, particularly the molars on the right side, so that the lateral skeletal discrepancy could be camouflaged. Following levelling and alignment of the teeth in both arches with fixed appliances, buccal miniscrews were placed between the lower first and second molars and buccal extended arms added to the first molar bands (Figure 12a). The molars were moved distally with elastomeric chain between the miniscrews and arms, and coil springs between the molars. After the anterior crossbite had been corrected a palatal arch with hooks was added to the upper first

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Figure 13. Post-treatment intra-oral photographs of Case 3.

Figure 14. Pre- and post-treatment cephalometric tracings of Case 3.

molar bands and the upper arch retracted and intruded using the palatal miniscrews (Figure 12b). The case responded well to the treatment and the mandibular lateral skeletal discrepancy was less conspicuous (Figures 11 to 14). The treatment time was 2 years and 2 months. Throughout treatment the patient had myofunctional therapy, which may assist with retention. Miniscrews, as temporary anchorage devices, offer new possibilities in orthodontic treatment. The choice of teeth to be extracted does not depend on the anchorage value, teeth can be moved in directions which are often not possible with conventional fixed methods, and compliance is usually assured. Direct forces from a miniscrew to a tooth are a simple and effective means of moving teeth. Indirect forces,

which offer a wider range of manoeuvres than simple direct forces, usually require a palatal arch and extended arms soldered to either the upper or the lower molar bands.

Summary
Miniscrews, in combination with palatal arches with hooks and extended arms from the first molars, can be used to correct malocclusions in non-compliant patients and malocclusions that are difficult to treat using traditional methods.

Acknowledgments
To the dedicated scientists and clinicians responsible for developing temporary anchorage devices.

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Corresponding author
Dr George Anka Keio Seiseki Sakura Gaoka A Bldg. 2F Sekido 1-11-1 Tama-shi Tokyo Japan Tel: 00 81 42 337 2525 Fax: 00 81 42 339 0918 Email: Anka467@poplar.ocn.ne.jp

References
1. Anka G. Use of miniscrews as temporary anchorage devices. I Introduction. Aust Orthod J 2006;22:1319. 2. Anka G. Management of non-compliant Class II Div 1 extraction cases with jumping appliance Forsus DPR a suggestion of the use of Gurin lock and anterior fixed bite plate. Ortodontia 2004;9:12233. 3. Cole WA. Accuracy of patient reporting as an indicator of headgear compliance. Am J Orthod Dentofacial Orthop 2002;121:41923. 4. Agar U, Doruk C, Bicakci AA, Bukusoglu N. The role of psycho-social factors in headgear compliance. Eur J Orthod 2005;27:2637. 5. Tong H, Chen D, Xu L, Lui P. The effect of premolar extractions on tooth size discrepancies. Angle Orthod 2004;74: 50811. 6. Boley JC, Mark JA, Sachdeva RC, Buschang PH. Long-term stability of Class I premolar extraction treatment. Am J Orthod Dentofacial Orthop 2003;124:27787. 7. Janson G, Brambilla AC, Henriques JF, de Freitas MR, Neves LS. Class II treatment success rate in 2- and 4-premolar extraction protocols. Am J Orthod Dentofacial Orthop 2004;125:4729. 8. Beckmann SH, Segner D. Changes in alveolar morphology during open bite treatment and prediction of treatment result. Eur J Orthod 2002;24:391406. 9. Proffit WR, Bailey LT, Phillips C, Turvey TA. Long-term stability of surgical open-bite correction by Le Fort I osteotomy. Angle Orthod 2000; 70:1127. 10. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open-bite treatment. Angle Orthod 2007;77:4756.

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Molar distalisation with skeletal anchorage


Antonio Gracco, Lombardo Luca and Giuseppe Siciliani
Department of Orthodontics, University of Ferrara, Ferrara, Italy

Background: Distalisation of the upper molars can be used to treat a dental Class II deep bite malocclusion with a flat facial profile. It is a useful procedure when extraction treatment has been refused and providing distalisation is an appropriate solution to the patients problem. Aims: To describe distalisation of the upper buccal segments using a modified distal jet appliance and miniscrew. Methods: Two case reports are presented. The first case was treated with a distal screw appliance: a modified distal jet appliance with a palatal miniscrew and without the premolar arms. The Nance button was anchored to the palatal bone by a miniscrew inserted through a posterior locating plate. Locating holes in the plate ensured that the miniscrew was inserted into a site with optimal bone in the posterior part of the palate. The second case was treated with a similar distal screw appliance, but in this case the locating plate was embedded in the acrylic button. The miniscrew was inserted through a prepared hole in the button and plate. The locating hole(s) ensured that a screw could be inserted into an optimal site to one side of the median palatal suture. Conclusions: The distal screw appliance can be used to distalise upper teeth with minimal or no anchorage loss. (Aust Orthod J 2007; 23: 147152)
Received for publication: August 2007 Accepted: September 2007

Introduction
Class II malocclusions occur in a significant number of orthodontic patients. Distalisation of the upper molars, aimed at increasing the lengths of posterior buccal segments, is a frequently used method of treatment for this condition.1 This type of therapy is indicated in patients with a normal or hypodivergent face, a deep bite with or without a flat facial profile, missing upper third molars, and when patients and/or their guardians refuse extraction treatment and the orthodontist deems nonextraction treatment appropriate ethically. It is contraindicated in patients with increased facial divergence or a skeletal open bite as distalisation may result in extrusion of the upper molars, and an increase in the vertical skeletal dimension and backward and downward movement of the mandible. Typically, the upper molars are moved distally before the premolars and anterior teeth are retracted. Distalisation is more effective if it is carried out before the premolars have emerged and prior to emergence of the upper second molars as it allows the leeway space to be exploited.2,3 Distalisation at this time
Australian Society of Orthodontists Inc. 2007

significantly shortens the treatment time and lessens the need for extractions.4 The popularity of distalisation has led to the evolution of a large number of intra-oral and extra-oral appliances for this purpose. Extra-oral appliances, such as headgear, rely on a system of anchorage located external to the oral cavity to discharge the unwanted reaction forces. Intra-oral devices, on the other hand, may be subdivided into single arch and intermaxillary or two arch appliances. The former are usually used in the upper jaw and may include: NiTi springs and wires, magnets, Jones jig, pendulum and the distal jet appliances.510 Two arch appliances, which exploit the mandibular arch for anchorage, include devices such as: the Herbst appliance, Jasper jumper, cantilever bite jumper, mandibular anterior and repositioning appliance (MARA) and eureka spring appliance.11,12 Of the devices available for distalisation, we prefer to use a modification of Caranos distal jet appliance because it achieves about the same amount of distalisation in the same time frame as other distalising appliances. The distal jet appliance also leads to less
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Figure 1. Initial version of the distal screw appliance (left) and latest version (right). Note the absence of stabilising arms, the positions of the locating plates and the locating holes for the miniscrews.

tipping during distalisation, it does not produce unwanted vertical changes, it does not rely on patient compliance and, finally, after the active distalisation phase the Nance button can be used for anchorage control.10,13

Graz implant-supported pendulum, the bioresorbable implant anchor for orthodontics system, the Straumann orthosystem, the Frialit-2 implant system, the Oric implant system, the onplant system and, more recently, non-osseointegrated or partially osseointegrated orthodontic miniscrews.16 In order to achieve distalisation of the upper molars without anchorage loss, Carano combined the distal jet appliance with miniscrews.17 He placed the miniscrews palatally in the interradicular spaces either between the premolars or between the molars and premolars. He chose these sites based on work carried out by Poggio,18 who indicated that the optimal sites for implants in the maxilla were the interradicular spaces between the first molar and second premolar, the first and second molars and the first and second premolars. However, these sites are not without complications. Insertion of miniscrews between the molar and premolar roots requires a surgical protocol, does not allow good oral hygiene and, most importantly, impedes distal movement of the premolars. For these reasons we modified the original distal jet appliance to exploit skeletal anchorage in the palate. We also simplified the device and placement of the miniscrews and reduced the bulk of the appliance. In order to discover the ideal sites for miniscrews in the palate, we measured the thickness of the palatal bone at four sites on both sides of the median palatal suture in children and adolescents between 10 and 15

Distal screw appliance


Use of the distal jet appliance, as with all intra-oral distalising appliances, involves a certain amount of anchorage loss, which consists of an unwelcome mesial movement of the premolars and an increase in overjet.1 Indeed, Nishii et al.,14 who used a distal jet appliance, found that the second premolars moved 0.6 mm mesially for each millimetre of molar distalisation. Furthermore, they observed that the maxillary incisors also moved labially (approximately 2.4 mm of labial movement per millimetre of distalisation) and proclined approximately 4.5 degrees. Ngantung et al.15 observed that greater mesial tipping (approximately 12.2 degrees) occurred if the upper arch was banded at the time distalisation was undertaken. Anchorage stability is often an essential factor for the successful treatment of Class II malocclusions, and unstable anchorage can lead to unfavourable occlusal relationships and complicate subsequent treatment procedures. Many implant systems have been employed in attempts to ensure stable skeletal anchorage during molar distalisation such as: the
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Figure 2. Case 1. Pretreatment intra-oral views of the mild Class II malocclusion in a 12 year-old girl.

years of age.19 We found that the palatal bone thinned progressively from anterior to posterior and from medial to lateral. Our data supports Carano and co-workers,13 that the anterior paramedian regions of the palate are the sites of choice for miniscrews. In children and adolescents the thickest bone was found 48 mm behind and 6 mm lateral to the incisive foramen. Posterior sites are suitable for implants, despite the fact there is less bone, because in this area there are double cortical plates covered with thin mucosa.19 Based on these data we modified the original distal jet appliance by removing the arms for premolar anchorage and adding a stainless steel locating plate to the Nance button. We have called this appliance the distal screw appliance. Initially, we tried adding a shaped stainless steel plate to the posterior periphery of the Nance button. The plate had holes for miniscrews at appropriate distances on both sides of the median palatal suture. In our latest version we have incorporated the locating stainless steel plate into the resin and pierced both resin and plate with six holes, 3 mm and 6 mm on both sides of the median palatal suture (Figure 1). The holes in this latest modification take advantage of the thicker bone anteriorly and, as a result, the appliance is more secure than our first design. The distal screw appliance has some additional advantages over the conventional distal jet appliance. By removing the premolar stabilising arms the

appliance is less bulky and spontaneous distalisation of the premolars can occur in the early stages of treatment. Furthermore, the combination of the Nance button and a palatal miniscrew provides maximum anchorage upon completion of distalisation. Unlike other intra-oral distalising appliances, which require the upper molars to be distalised before the premolars and anterior teeth can be retracted, the distal screw appliance allows the premolars to move spontaneously or to be moved distally. Once a Class I molar relationship has been achieved any residual spaces in the upper arch can be closed. In our experience this appliance results in shorter treatment and chair times and requires less patient compliance than other designs.

Case 1
A 12 year-old girl with a Class II malocclusion presented in our clinic and we decided to treat the problem by distalising the upper molars (Figure 2). We used a distal screw appliance with a pierced locating plate extending posteriorly from the Nance button and a 9 mm miniscrew. The appliance was activated monthly and the upper molars were distalised without loss of anterior anchorage in 4 months (Figures 3 and 4). During treatment the premolars spontaneously moved distally (Figure 4). We found that the upper first molars were moved distally 3.88 mm and tipped distally 3.08 degrees with
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Figure 3. Case 1. Molar distalisation with the initial design and spontaneous distal movement of the upper second premolars.

I dental relationship we decided to distalise the upper molars with a distal screw appliance. We removed the premolar arms and embedded a stainless steel locating plate in the Nance button. The plate and acrylic had holes for miniscrews, 3 mm and 6 mm on both sides of the median sagittal plane. In this case a single 1.5 mm diameter, 9 mm miniscrew was used. After 9 months treatment a Class I molar relationship was achieved. (Figures 5 and 6).
Figure 4. Case 1. Pre- and post-distalisation tracings superimposed on maxilla.

respect to the base of the cranium.20 There was no appreciable change in the position of the upper incisors. The premolars spontaneously moved 1.68 mm distally and tipped 3.74 degrees distally. Our data agrees with the data published by Carano, who reported a mean molar distalisation of 3.2 mm and distal tipping of 3.1 degrees in 20 patients treated with the distal jet appliance.1 However, Caranos appliance resulted in the upper premolars moving mesially 1.3 mm and tipping 2.8 degrees mesially.1

The upper occlusal photographs show how the absence of the stabilising arms on the premolars permitted spontaneous distal migration of the anterior teeth and partial resolution of the crowding. On tracings of the patients pre- and post-treatment cephalometric radiographs the upper molars were distalised 3.88 mm and tipped distally 3.08 degrees. The premolar crowns also moved 1.68 mm distally and tipped 3.74 degrees distally while the incisors remained more or less stable. (Figure 7).

Conclusions
The distal screw appliance is a modified distal jet appliance without the premolar arms and with a locating plate embedded in the Nance button. The locating plate allows a miniscrew to be placed in the thick palatal bone to one side of the median palatal suture. The absence of the premolar arms permits the premolars to spontaneously move distally. It can be used to distalise the teeth in the upper arch with

Case 2
This 15 year-old male adolescent presented at our clinic with a Class II malocclusion, a hypodivergent profile and slight anterior crowding. To obtain a Class
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Figure 5. Case 2. Pretreatment intra-oral views of the mild Class II malocclusion in the 15 year-old male patient.

Figure 6. Case 2. Molar distalisation with the latest design of the distal screw appliance and spontaneous distal movement of the second premolars.

Figure 7. Case 2. Pre- and post-distalisation tracings superimposed on maxilla. Note there was minimal change in the upper incisors.

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minimal or no anchorage loss and in a relatively short treatment time. The appliance does not rely on patient compliance.

8. 9. 10.

Corresponding author
Antonio Gracco Via E. Scrovegni 2 35100 Padova Italy Tel: +39 (0532) 202 528 Fax: +39 (0532) 202 528 Email: antoniogracco@libero.it

11.

12. 13. 14.

15.

References
1. Bolla E, Muratore F, Carano A, Bowman J. Evaluation of maxillary molar distalization with the distal jet: a comparison with other contemporary methods. Angle Orthod 2002; 72:48194. Gianelly AA. A strategy for nonextraction Class II treatment. Semin Orthod 1998;4:2632. Gianelly AA. Leeway space and the resolution of crowding in the mixed dentition. Semin Orthod 1995;1:18894. Gianelly AA. Crowding: timing of treatment. Angle Orthod 1994;64:41518. Gianelly AA. Distal movement of the maxillary molars. Am J Orthod Dentofacial Orthop 1998;114:6672. Kalra V. The K-Loop molar distalizing appliance. J Clin Orthod 1995;29:298301. Blechman AM. Steger ER. A possible mechanism of action of repelling, molar distalizing magnets. Part I. Am J Orthod Dentofacial Orthop 1995;108:42831. 16. 17.

2. 3. 4. 5. 6. 7.

18.

19.

20.

Jones RD, White JM. Rapid class II molar correction with an open-coil jig. J Clin Orthod 1992;26:6614. Hilgers JJ. The pendulum appliance for Class-II noncompliance therapy. J Clin Orthod 1992;26:70614. Carano A, Testa M. The distal jet for upper molar distalization. J Clin Orthod 1996;30:37480. Beccari S, Sfondrini G, Gandini P. The Herbst and Jasper Jumper method in the orthodontic fixed appliance. Ortognatodonzia Italiana 1992;4:52540. Blackwood HO. Clinical management of the Jasper Jumper. J Clin Orthod 1991;25:75560. Carano A, Testa A, Bowan J. The distal jet simplified and updated. J Clin Orthod 2002;36:58690. Nishii Y, Katada H, Yamaguchi H. Three-dimensional evaluation of the distal jet appliance. World J Orthod 2002;3: 3217. Ngantung V, Nanda RS, Bowman SJ. Postreatment evaluation of the distal jet appliance. Am J Orthod Dentofacial Orthop 2001;120:17885. Papadopoulos M. Orthodontic treatment of the class II noncompliant patient. Mosby, Elsevier, 2006:1554. Carano A, Velo S, Leone P, Siciliani G. Clinical implications of the miniscrew anchorage system. J Clin Orthod 2005;39: 924. Poggio PM, Incorvati C, Velo S, Carano A. Safe Zones: a guide for miniscrew positioning in the maxillary and mandibular arch. Angle Orthod 2006;76:1917. Gracco A, Lombardo L, Cozzani M, Siciliani G. Quantitative evaluation with CBCT of palatal bone thickness in growing patients. Prog Orthod 2006;7:16474. Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod Dentofacial Orthop 1996;110:63946.

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Editorial

What is a minimal clinically important difference?


In his Comment Professor Herbison mentions MCID or minimal clinically important difference, which has been defined as, the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patients management.1 Other more straight-forward definitions are, the smallest difference in a score that is considered to be worthwhile or important,2 the minimum absolute risk reduction for which patients would take a treatment given their understanding of the risk without that treatment3 or, an interesting variation, the mean score for an optimal result minus the mean score for a group with a suboptimal result.4 Quite simply it is the smallest difference patients (and clinicians) would care about. When we get around to using them in orthodontics MCIDs will first, and foremost, tell us what is clinically important and what isnt. As Professor Herbison mentioned, a MCID is often larger than a statistically significant difference, which in the absence of a clinically significant difference might be of little practical importance. They will help us judge the benefits when comparing two methods of treatment (e.g. functionals and headgear or early and late treatment); they will help researchers who are planning studies to calculate the sizes of their samples and, therefore, will give us information on the usefulness of their data; they will enable us to make inferences about the percentage of patients improved by a method of treatment; and they will allow us to make cost-effectiveness comparisons.5 With MCIDs we will have a much better idea what are appropriate and effective methods of treatment. A MCID is more likely to be context-specific (i.e. the conditions present when something like a 5 mm reduction in overjet occurs) than a fixed number such as a 5 mm reduction in overjet with no conditions.6 Finding out what is clinically important might start with a discussion with colleagues and patients and end up gathering both subjective and objective information. The input from patients could be in the form of a quality of life questionnaire, and from the clinicians a measurement of, say, overjet, crowding or use of a rating scale. As you can imagine there will be disagreements as to what constitutes a MCID because there will be different opinions of what is clinically important. But according to some authors there are solutions to virtually all the scientific hurdles.7,8 Of the nine methods used in medicine to measure a MCID the method that attracted me was the one that does not rely on memory and does not require longitudinal follow-up.9 Instruments that rely on memory are fallible and may provide misleading evaluations of what patients actually experienced.5,10,11 Part of the problem comes when they are asked to remember the frequency of events over a fixed period of time (e.g. In the last three months how often have you had sores in the mouth? Can you remember?). Problems can also occur when patients are lost from the study, if they cant be bothered answering the same questionnaire time and time again or if the quality of their responses diminishes over time. The innovative approach used by Redelmeier et al.10,11 gets around the problem of relying on patients memories by pairing patients with the same condition and asking them to compare themselves with their pairs rather than relying on their memories of the past condition. Clinician administered surveys or measures can be used as well. Although the method has some disadvantages, such as the difficulty of assembling a representative group of patients for a sufficient period of time, its advantages may more than compensate for its disadvantages.5,11 But devising a MCID may be just the start of the story: it has been suggested that a MCID (or for that matter one of the indices we use) for improvement may not be the same as one for deterioration: this should be followed-up.6 Measurement errors, MCIDs and quality of life instruments have not received the attention they deserve from the profession. Some of the innovative approaches used in medicine may be of value to us. Michael Harkness

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References
1. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989;10:40715. Hays RD, Woolley JM. The concept of clinically meaningful difference in health-related quality of life research. PharmacoEconomics 2000;18:41923. Man-Son-Hing M, Laupacis A, OConnor A et al. Warfarin for atrial fibrillation; the patients perspective. Arch Intern Med 1996;156:18418. Quinn JV, Wells GA. An assessment of clinical wound evaluation scales. Acad Emerg med 1998;5:5836. Wright JG. The minimal important difference: Whos to say what is important? J Clin Epidemiol 1996;49:12212. Beaton DE, Boers M, Wells GA. Many faces of the minimal clinically important difference (MCID): a literature review and directions for future research. Curr Opin Rheumatol 2002;14:10914.

7.

2.

3.

4. 5. 6.

Sloan JA. Assessing the minimally clinically significant difference: scientific considerations, challenges and solutions. COPD 2005;2:5762. 8. Kirwan J. Minimal clinically important difference: the crock of gold at the end of the rainbow? J Rheumatol 2001;28: 43944. 9. Wells G, Beaton D, Shea B et al. Minimal clinically important differences: Review of methods. J Rheumatol 2001;28: 40612. 10. Redelmeier DA, Guyatt GH, Goldstein RS. Assessing the minimally important difference in symptoms: A comparison of two techniques. J Clin Epidemiol 1996;49:121519. 11. Redelmeier DA, Guyatt GH, Goldstein RS. On the debate over methods for estimating the clinically important difference. J Clin Epidemiol 1996;49:12234.

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Australian Orthodontic Journal Volume 23 No. 2 November2007

Letter

Letters and brief communications are welcomed and need not concern what has been published in the Australian Orthodontic Journal. We will print experimental, clinical and philosophical observations, reports of work in progress, educational notes and travel reports relevant to orthodontics. We reserve the right to edit all Letters to meet our requirements of space and format. All financial interests relevant to the content of a Letter must be disclosed. The views expressed in Letters represent the personal opinions of individual writers and not those of the Australian Society of Orthodontists Inc., the Editor, or BPA Print Group Pty Ltd.

Force and tooth movement

Sir, I am writing in response to the article in the last issue of the Journal by Drs Hong, Woods and Stella on the topic of 3D-CT radiographic scanners.1 The authors mention a number of ways the data collected by these scanners can be applied in dentistry. With specific reference to their uses in orthodontics, the authors refer to recent work measuring the cross-sectional area and volume of muscles. The maximum crosssectional or projected area of the tooth roots can also be obtained and is the dimension which, knowing the value of the force applied, provides us with the average pressure exerted on the tissues surrounding a tooth during orthodontic tooth movement. This writer2 and Ren, Maltha and Kuijpers-Jagtman3 conducted experiments relating force and tooth movement. When the forces to obtain optimal rates of tooth movement were converted to pressures by dividing the force values by the average value of the projected root area of the distal surface of upper cuspid (0.97cm2), the average optimum pressure for this writers experiment was 203 cN cm-2. In Rens experiment the force level at which the highest rates of tooth movement occurred was, in most subjects, 200 cN giving an average optimum pressure of 206 cN cm-2, both experiments confirming the estimates of Jarabak and Fizzell,4 based on Smith and Storeys results.5,6 These are average values. Individual values may vary according to bone density. This information is also obtainable from the scanners. Other dimensions obtainable are total root volume and the volume of the root enclosed in bone. These together with projected area, could enhance the accuracy of the determination of the appropriate force to apply, whether for anchorage or for tooth movement another field of research to lead on

from Dr Chris Miles study of the root volume of the permanent dentition.7 It is clear that these scanners will provide us with much more information, enabling us to prescribe forces, which will deliver optimal rates of movement and treat our patients as individuals, rather than treating them with one dosage of force delivered by the one type of appliance. Brian Lee 3 Lynden Road Bonnet Hill Tasmania 7053 Australia Email: bjlee3@bigpond.com

References
1. Hong JC, Woods M, Stella D. Three-dimensional computed craniofacial tomography (3D-CT): potential uses and limitations. Aust Orthod J 2007;23:5564. Lee BW. The force requirements for tooth movement, Part III: the pressure hypothesis tested. Aust Orthod J 1996;14: 937. Ren Y, Maltha JC, Vant Hof MA, Kuijpers-Jagtman AM. Optimal force magnitude for orthodontic tooth movement: a mathematical model. Am J Orthod Dentofacial Orthop 2004;125;717. Jarabak JR, Fizzell JA. Technique and treatment with the lightwire appliances: light differential forces in clinical orthodontics. St. Louis: Mosby, 1963. 35379. Storey E, Smith R. Force in orthodontics and its relation to tooth movement. Aust J Dent 1952;56:1118. Storey E, Smith R. The importance of force in orthodontics. Aust J Dent 1952; 56:291304. Miles C. An analysis of tooth root volume. Masters thesis 1986, University of Melbourne.

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Comment

Why would anyone be interested in measurement error?


Many papers in orthodontics start the results section with an assessment of measurement error. For some or all measurements a proportion is measured again, Dahlbergs formula is applied and the results presented.1 It is almost a rite of passage for a paper, but it is not always appropriate and often it is an unnecessary complication for the paper and does not aid interpretation. When talking about the results for groups of people then the measurement error is almost irrelevant in the absence of bias. An unbiased measurement is made up of two parts, the true measurement and the measurement error: Recorded measurement = true measurement + measurement error The measurement error has special properties, it will be centred around zero, as there is no reason to suspect a bias. Results close to zero will be more common than those far from zero, and negative results would be just as common as positive results. This distribution of results is called the normal distribution of errors, usually just the normal distribution. One consequence

of this is that if you repeatedly measure the same dimension the sum of the errors will approach zero as the positive and negative values cancel each other out. It follows that for a reasonable number of measurements the sum, and therefore the mean of the recorded measurements, is the same as the sum or the mean of the true measurements. Thus, when using the mean of a number of measurements of the same dimension the measurement error does not affect the mean, and also it will not affect the difference between two means. What the measurement error does affect is the standard deviation, and as a consequence the standard error of the mean is larger the larger the measurement error. Thus, with increasing measurement error, the difference between the means of two groups has to increase before it is statistically significant. When using a measurement there are two properties to keep in mind: reproducibility and validity. The reproducibility has to do with measurement error: it is whether you get the same result if you repeat the same measurement. The validity is to do with bias, whether the measurement is a good estimate of the true value. The relationship between these is shown in the figure. The illustration clearly shows that for the interpretation of measurements, validity is much more

Reproducible Yes xxxxxxxxx Yes Valid xxxxxxxxxx No True value True value True value x x x xxx True value xxxx x x x No xxx xx xx

Figure. Reproducibility and validity.

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important than reproducibility. If the measure is valid then you still get an approximation to the true answer, even though a lack a reproducibility makes this less precise. Validity is often not an issue in orthodontics as lengths and angles are the usual type of measurements, and there is no obvious reason why these may not be valid with good technique and if landmarks are identified consistently. Where reproducibility may be an issue is when you are trying to apply results to individuals. The number given by Dahlbergs formula1 is the amount that may be due to measurement error. So to be sure that the measurement has changed in an individual it should be larger than this value. This should not be confused with the minimally clinically important difference (MCID),24 which is the difference that needs to happen before the patient thinks that it is worthwhile. The MCID contains both objective and subjective information. It would almost certainly be larger than the number given by Dahlbergs formula. Of course all efforts should be taken to prevent bias (which is a systematic lack of validity) from affecting measurements. For example, landmarks should be consistently identified, different magnifications should be allowed for and skulls, or heads, should be consistently orientated before taking radiographs or photographs. Other commentators on errors have concentrated on reducing bias,5 but bias and reproducibility are independent it is possible to have bias in a highly reproducible measurement or no bias in an unreproducible measurement. So in conclusion, if the paper is presenting the results for groups, or for differences between groups, it is hard to see how measurement error is useful in the interpretation of the results. It is only if the results are to applied to individuals that it becomes useful, but in that case a MCID, which is more difficult to determine, is even more useful. Peter Herbison Department of Preventive and Social Medicine Dunedin School of Medicine PO Box 913 Dunedin 9054 New Zealand Tel: 00 64 3 479 7217 Fax: 00 64 3 479 7298 Email: peter.herbison@otago.ac.nz

References
1. 2. Dahlberg G. Statistical methods for medical and biological students. New York: Interscience,1940:905. Neely JG, Karni RJ, Engel SH, Fraley PL, Nussenbaum B, Paniello RC. Practical guides to understanding sample size and minimal clinically important difference (MCID). Otolaryngology Head & Neck Surgery 2007;136:1418. Barrett B, Brown D, Mundt M, Brown R. Sufficiently important difference: expanding the framework of clinical significance. Med Decis Making 2005;25:25061. Wells G, Beaton D, Shea B, Boers M, Simon L, Strand V et al. Minimal clinically important differences: review of methods. J Rheumatol 2001;28:40612. Houston WJB. The analysis of errors in orthodontic measurements. Am J Orthod 1983;83:38290.

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When should we finish with a Class I molar relationship?


The best evidence can inform, but can never replace, individual clinical expertise because it is this expertise which decides whether the evidence applies to the individual patient and, if so, how it should be integrated into a clinical decision.1

Like many professions we should review the concepts we use daily in our practices. In this technological age we have the ability to access and appraise information that may be important to our specialty and, if necessary, change our working hypotheses.1 I have been struck by the confusion that can arise in the minds of our students and non-orthodontists with one of our most fundamental concepts: the Class I molar occlusion. When should we consider alternatives to a Class I molar occlusion? With the popularity of nonextraction treatment and the availability of preformed archwires and other matriel required to treat malocclusion, it is inevitable that an increasing number of non-specialists will take up orthodontic treatment. What the profession must remember is that these people lack the knowledge and experience of the specialist and generally accept concepts that we may question or may have even discarded. Since Angle2 described normal occlusion and attributed the greatest importance to the first permanent molars, we have used the Class I occlusion of the first molars as the ideal occlusion.3 Obviously, there are circumstances when alternatives to a Class I occlusion should be considered, but what are they? I attempted to find an

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answer to this question by systematically searching the electronic database for the best available evidence. I also hand-searched six well-known orthodontic journals: the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the European Journal of Orthodontics, the World Journal of Orthodontics, the Journal of Orthodontics and the Journal of Clinical Orthodontics. I looked for relevant clinical papers and case reports, which might provide me with the evidence needed to answer my question. In view of the lack of articles in the literature, I had to fall back on the case report sections published in the above mentioned orthodontic journals. The following is a brief illustration of some of the published case reports to highlight the problem: The British Journal of Orthodontics, Case Report Section: 1. Hickman4 published two cases that had been submitted for the William Houston Gold Medal in 1997. In his first case report, Hickman stated that one of the aims of treatment was to, Produce a good buccal segment cusp fossae relationship and functional occlusion. In the treatment plan he mentioned that, The molar relationship was to be a full unit Class II between the upper first molars and the lower second molars, and the upper first premolars were to mimic the maxillary canines. But in his second case report the aim of his treatment was to, . . . produce Class I mutually protected functional occlusion, camouflaging the mild Class II skeletal discrepancy with . . . 2. Foong5 also published two cases and he had more or less the same treatment plan which was directed to, Achievement of good occlusal interdigitation for improved stability of treatment and function. He mentioned in the post-treatment assessment that, . . . the incisors and canines showed a good Class I relationship and continued, The molar relationships were in full Class II because of upper second premolar extractions. In his second case he mentioned that, Good occlusal interdigitation and arch alignment were obtained at the end of treatment. The post-treatment intra-oral photographs of this case showed that incisors, canines and first molars were in good Class I relationships. 3. Mullane6 published two cases and stated in the aims of treatment that he intended, To establish a Class I buccal segment relationship bilaterally.
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In the World Journal of Orthodontics: 1. Costa Pinho et al.7 described camouflage treatment of a case with a skeletal Class III malocclusion. They stated in the treatment plan that, An overjet and overbite correction was then attempted, by obtaining a Class I canine relationship, and therefore, a functional occlusion . . .. In their conclusion they stated that, The proposed treatment objectives were achieved. These objectives were to obtain a stable dental articulation, good esthetics, and functional results in spite of the skeletal disharmony and dental Class III malocclusion. The American Journal of Orthodontics and Dentofacial Orthopedics: 1. Bilodeau,8 in an American Board of Orthodontics case report, pointed that his first objective was to, Correct the Class II dental relationship. 2. Popp et al.9 in their case report, Nonsurgical treatment for a Class III dental relationship: A case report; stated in their treatment objectives; 2. To establish Class I canine relationship. and 6. To establish a functional occlusion. However, in the treatment plan their second point was to, Establish Class III molar and Class I canine relationship. Confused? From these case reports published in three of our most prestigious journals one could conclude that a Class I molar relationship at the end of treatment is a matter of debate. It appears to me that we have at least two schools of thought. The first school belongs to the group that believes a Class I molar relationship is the main objective of orthodontic treatment. Interestingly, Popp et al.9 acknowledged the existence of an alternative form when they concluded that, Although some may not consider this an ideal occlusion, balanced tooth contact can be obtained in a Class III relationship. The second school holds the view that Class II or III molar relationship is acceptable providing that there is a balanced functional occlusion and Class I canine relationship. In this regard occlusal equilibration after treatment could be considered as an essential part of an orthodontic treatment protocol. I would be interested to know when a Class I molar relationship should be a treatment objective and when it need/should not be an objective? Hussam M. Abdel-Kader Orthodontic Department Faculty of Dental Medicine

COMMENT

Al-Azhar University Cairo Egypt Tel: +202-3305-0468, +202-3749-0983 Email: hmkader@hotmail.com Web site: http://www.geocities.com/hussamkader

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References
1. Harrison EJ. Current products and practice; Evidence-based orthodontics: where do I find evidence? J Orthod 2000;27: 718. Angle FH. Classification of malocclusion. Dental Cosmos 1899;41:24864. Andrews L. The six keys to normal occlusion. Am J Orthod Dentofacial Orthop 1972;6:296309. Hickman J. The William Houston Gold Medal 1997. Clinical Section, Br J Orthod 1999;26:818.

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Foong KW. The Gold Medal Prize in the Conjoint M. Orth. Exam of the Royal College of Surgeons of Edinburgh Held in Hong Kong, 1996. Clinical Section, J Orthod 2000;27: 110. Mullane C. The William Houston Gold Medal 1998. Clinical Section, BJ Orthod 2000;27:11925. Costa Pinho TM, Ustrell Torrent JM, Correia Pinto JGR. Orthodontic camouflage in the case of a skeletal Class III malocclusion. World J Orthod 2004:5:21323. Bilodeau JE. American Board of Orthodontics Case Report. Am J Orthod Dentofacial Orthop 1997:111:48791. Popp TW, Gooris CGM, Schur JA. Nonsurgical treatment for a Class III dental relationship: A case report. Am J Orthod Dentofacial Orthop 1993:103:20311.

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Obituary

Thomas Graber
1917 2007

Tom Grabers achievements and involvement in dentistry have been adequately dealt with in other publications1 and supplementary literature and do not require repetition here. I have therefore confined this obituary to my personal associations with him both here and at conferences overseas. Tom visited Australia more than once and at his first visit lectured to State Branches of the Australian Society of Orthodontists. He opened his lecture to the Victorian Branch showing his first slide, which was a photograph of the mushroom cloud of an atomic explosion, with the words, This picture represents the effect that the Begg Technique is having on orthodontics in the United States. At a time when orthodontic teaching was largely empirical and the predominant technique used in Melbourne was that according to Strangs text book, this came as rather a shock to his audience. He focused the attention of Australian orthodontists on the work of Dr Begg but ironically lived long enough to see the technique wane as an entity but survive in the adoption by other techniques of the use of lighter forces exerted over a long range of action. His nature has been variously described as generous, humane, compassionate, vibrant, interesting and exuberant. As well, I found him to be loving of his craft and dedicated to his profession. Brian W. Lee
1. Am J Orthod Dentofacial Orthop 2007;132:2723.

I have known Tom Graber for many years. My husband Milton first met Tom when we were in the United States, 1960-63. Thanks to Tom we had a number of introductions to orthodontists in Europe. We travelled through Europe for several months on our way home to Australia in 1963. Milton kept up a constant correspondence with Tom, and I finally met him at an orthodontic meeting in Chicago in 1977. He gave me the impression of being such a vibrant, interesting and friendly person. We had travelled to Chicago with our youngest son Michael, who was then 12. Tom and his gracious wife Doris took us to their holiday home by a beautiful lake for several days. We did have such a happy and relaxing time, although Tom was always on the go. Michael turned 13 while there and Tom took us and several others to a Bunny Club on his birthday. A birthday he has never forgotten! Since then I have met Tom at orthodontic meetings in many places. He and Doris have travelled to many exotic places, and he kept himself remarkably fit. He was a wonderful host and enjoyed good food, wine and company. We also had the privilege of visiting him and Doris in their home in Chicago. The last time I saw Tom was at the orthodontic meeting in San Francisco in 2005. Although in his eighties, he was still full of vitality and passionate about orthodontics. He wrote me such a lovely letter when Milton passed way suddenly last year. He started with Sad, Sad, Sad. Tom, I feel the same about you. Helen Sims

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Book reviews
Skeletal Anchorage with Microimplants
A. Korrodi Ritto
Publisher: Facies (www.ritto-appliance.com) Price: Euro125 ISBN: 978 972 99576 3 5

In addition, arguments of low invasiveness and low costs that are put forward, imply universal application but neglect emphasising that the essential starting point is adequate orthodontic diagnosis to determine whether or not such anchorage is needed. Thus, inexperienced clinicians taking their first steps with the aid of this text are being misdirected to unnecessary use of these screws, while also being encouraged to embark on correction of complex malocclusions for which they may not be adequately equipped to keep out of trouble. Perhaps this text would be of some use in a special learning situation that links applications of the principles of orthodontic diagnosis and mechanics with the use of microimplant anchorage, also providing opportunity for hands-on, guided, experience. Keith Godfrey
Oral Cavity Reconstruction
Edited by Terry A. Day and Douglas A. Girod
Publisher: Taylor and Francis Group LLC Price: A$300.00 ISBN 10: 1-57444-892-7 ISBN: 978-1-57444-892-4

The expressed aim of the Portuguese author of this slim English language book (76 pages of text with 5 pages of references and 283 separate images) is to provide a practical manual and convenient reference work, particularly for those who intend to take their first steps in this area. The identity of the target readership is open to question, for it may be misconstrued as providing sufficient guidance for general dentists who wish to overcome their existing deficiencies in managing orthodontic anchorage. This publication provides basic descriptions, practical tips, and cautions in use of various types of microimplants, TADs, or whatever one wishes to call these screw devices. However, it assumes that the reader has adequate knowledge of the mechanical principles to be employed, such as identifying centres of resistance, and direction and amount of force applied for various orthodontic movements that are illustrated. This assumption is exemplified by the absence of any detail in the text and in most of the captions accompanying the illustrations (some even lacking adequate visualisation of auxiliaries used) to explain how the force devices were applied for tooth- or arch-segment movements. Also, some diagrams, particularly those relating to the use of palatal screw anchorage, ignore predictably adverse effects of various tooth-moving mechanisms that are illustrated. The book has numerous illustrated examples where the use of microimplant anchorage is highly questionable because of low anchorage requirements.

Orthodontists and orthodontic trainees occasionally have to deal with patients who have undergone surgical treatment for oral cavity tumours. This textbook, which is written in the United States, with contributions by Australian surgeons, provides an excellent overview to the care of patients who present with oral tumours, particularly the reconstructive aspects. There are excellent introductory chapters on the principles of oral cavity reconstruction, oral anatomy, function and physiology. There is a good overview of the various tumours that may affect the oral cavity, as well as some benign conditions, including osteoradionecrosis. The
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chapters on planning, diagnostic evaluation and surgical approaches to the oral cavity complement the introductory section. The anatomical challenges in reconstruction are tackled, including the lips, the buccal mucosa, the tongue and floor of mouth, the hard and soft palates, and the mandible. Each anatomical region has excellent diagrams and clinical photographs to assist the reader in understanding the complex issues of reconstruction. For completeness there is an excellent chapter presenting an overview of cleft lip and palate reconstruction in the infant. Prosthodontic issues are briefly dealt with, including the use of osseointegrated implants to support prostheses. The concluding chapters on the rehabilitation of speech and swallowing, functional assessment tools, quality of life and new horizons for the future cap off this excellent textbook. The quality of life issues may be of special interest to orthodontists who manage patients undergoing surgical orthognathic procedures. This book is recommended as background reading for orthodontists and orthodontic trainees who may have an interest in surgical oral cavity reconstruction. It is ideally suited to oral and maxillofacial, otololaryngology head and neck, and reconstructive plastic surgical trainees at the beginning of their training, to acquaint them with the range and spread of issues and options available in oral cavity reconstruction. David Wiesenfeld
Radiographic Cephalometry: From Basics to 3-D Imaging. Second edition
Alexander Jacobson and Richard L. Jacobson
Publisher: Quintessence Publishing Company, Inc. Price: US$110.00 ISBN: 0-86715-461-0

book is divided into chapters that first describe the role of cephalometrics, the history and techniques of cephalometrics followed by the more frequently utilised cephalometric analyses applied to contemporary orthodontic diagnosis. The latter chapters introduce the use of digital imaging and threedimensional cephalometry. The contributors include many eminent orthodontic and radiographic imaging experts, including Coenraad Moorrees, Richard Weems, Page Caufield, Scott McClure, Andr Ferreira, James Vaden, Herb Klontz, Lionel Sadowsky, Joseph Ghafari, Lysle Johnston, Shane Langley, Christos Viachos, David Sarver, Mark Johnston, William Harrell, David Hatcher and James Mah. This impressive list of contributors supports the excellence of the knowledge base compiled for the second edition of the textbook. Even with the numerous contributors to the textbook the authors have maintained a similar format and level of complexity within each area under discussion. The early chapters focus on the basic principles of utilisation of cephalometrics in diagnosis and treatment planning, and a brief history of the background leading up to, and the foundations of, the use of cephalometrics in orthodontics. The technical aspects and general principles of the cephalometer and obtaining an accurate radiograph are outlined. The basics of tracing techniques and landmark identification are clearly and concisely summarised. Each contemporary cephalometric analysis is summed up with a detailed description and good illustrations, along with applications of the analysis. Keeping pace with advances in 3-D cephalometric imaging the textbook illustrates the advantages and applications of the new technology to contemporary orthodontics. The final chapter is a critical discussion of the reliability of cephalometrics. The reality of the limitations of cephalometrics is discussed. The textbook is co-authored by Alex and Richard Jacobson, and as in their previous textbooks the illustrations are clear and easily interpreted. The authors and the publisher have arrived at a balance of colour and contrast that allows excellent representation of images. Where necessary, contrasting colours are utilised to clearly outline a diagram or make a point. The computer images are presented with outstanding clarity and definition. The sharpness of the images is carried over into the digital imaging and 3-D imaging chapters of the textbook.

Radiographic Cephalometry: From Basics to 3-D Imaging is an updated American book, which is published worldwide. This textbook sets the standard for application of cephalometrics in orthodontics. The
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BOOK REVIEWS

The textbook includes an extremely useful CDROM. Manual and digital tracing templates are available on the CD-ROM. These templates are valuable training tools and provide practical interpretation of cephalometric analysis. Also on the CD-ROM are video clips that illustrate the unique capabilities and functions of 3-D imaging. The video clips demonstrate 3-D imaging technology that would otherwise be difficult, if not impossible, to display within the pages of a textbook. Radiographic Cephalometry: From Basics to 3-D Imaging is a highly recommended and useful resource textbook for all medical and dental libraries, dental and postgraduate students and orthodontists and oral and maxillofacial surgeons. Mike Razza
Tip-Edge Plus Guide. 6th Edition
Peter Kesling
Publisher: TP Orthodontics, Inc (www.tportho.com) Price: US$109.15

The Sixth Edition contains comprehensive guidance on the use of the newest evolution of the appliance, the Plus bracket, which utilises a flexible auxiliary round wire through deep tunnels in each bracket to achieve final root positioning (including torque, in conjunction with full size rectangular wires in the bracket slot). The opening pages of The Guide outline the evolution of the Tip-Edge and Tip-Edge Plus appliance. Mention is made of the philosophy behind the differential straight-arch technique with specific reference to the individual components of the technique and so-called differential mechanics. This outline is also supported at the end of the text by a prcis of the concept of attritional occlusion, cited as central to the philosophy of the technique. Contemporary students of orthodontics may take exception to the application of the concept in a modern context, but as is often the case, offhand dismissal would leave a void in their knowledge and understanding. This is particularly so as much of current orthodontics embraces, knowingly and unknowingly, tenets of light-wire treatment. The section on diagnosis and treatment planning may be seen by some as simplistic and lacking sophistication. However the information put forward in this part is still useful and applicable in many situations and, it must be remembered, is not the primary focus of The Guide which is the appliance and technique. The appliance in question and its application in standard and common treatment situations are well-detailed in the body of the text. The latter part of The Guide sets out in succinct form the records of 28 cases treated with Tip-Edge Plus, followed by 16 pages of a question and answer series taken from the Tip-Edge Today newsletters. Following on are several selected articles from these newsletters. While such an archive can never cover all bases an examination of this part is almost sure to reveal to, or remind the reader of, some useful tips or gems of information. The Guide is completed by a good glossary and index. The overall text is supported by an extensive bibliography which may be seen nevertheless as not broad or comprehensive. The Tip Edge Plus Guide (Sixth Edition) would be a useful addition to any orthodontic library, bearing in mind its genesis and understandable bias. Stephen Langford
Australian Orthodontic Journal Volume 23 No. 2 November 2007

The Tip-Edge Plus Guide and The Differential Straight-Arch Technique (Sixth Edition) by Peter Kesling continues in hard cover form what essentially started out as a technique manual for the newly developed Tip-Edge appliance in the 1980s. The manual has evolved through its six editions and many revisions, but retains a core base of fundamental information which is unchanged. The book retains the look and feel of a specific technique/ appliance oriented manual. As such it is a valuable reference for protagonists of light-wire treatment and especially Tip-Edge operators. New students of TipEdge will find it particularly instructive when starting out and it is best combined with a well organised course given by qualified instructors who have years of experience and can demonstrate excellent results (Tip-Edge Plus Guide).

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Clinical Problem Solving in Orthodontics and Paediatric Dentistry


Declan Millett and Richard Welbury
Publisher: Elsevier (www.elsevier.com.au) Price: A$98.00 ISBN: 0443072655

retained deciduous molars and eventually replacing them with a prosthesis. The merits and consequences of each option are discussed. Some of the treatment approaches reflect the authors preferences and other alternatives are not always given. For example, in chapter 7, twin block therapy is described as a means of growth modification with a functional appliance. Other types of functional appliance therapy are not mentioned. Removable appliance treatment is also used in many cases where fixed orthodontic mechanics would be more efficient. This either reflects the authors preferences in mechanotherapy or removable appliance treatment is deemed more appropriate for dental students and general practitioners for whom the book is written. In summarising a particular topic the authors use a type of flow chart called Mind maps. Like the Key point concept, these would be useful for students during the revision process. I would recommend this text to dental students, general practitioners and dental educators wishing to demonstrate the concept of developing a logical approach to problem solving. Chris Theodosi

As outlined by the authors in the preface, this book has been written for dental students and dentists in their early years of practice. There are 37 chapters covering topics such as absent upper lateral incisors, anterior open bite, mottled teeth, oral ulceration and palatal canines. The format of the book is based upon a series of clinical scenarios representative of a range of problems encountered in paediatric dentistry and orthodontics. The scenarios are used as a basis for discussing the aetiology, diagnosis and treatment of the various problems which are addressed. The authors have set out each chapter in a very methodical fashion. The patient history is outlined, followed by the examination process which involves the various diagnostic tests and investigations needed to establish a problem list. Clinical photographs, radiographs, diagrams and tables are used effectively throughout the text. At the end of each chapter, a highlighted key point is noted. These key points create a very good overview of the subject and are designed to trigger information recall. When more than one treatment option is appropriate, these have been outlined with pros and cons of each option. For example, in chapter 6, the topic is infra-occluded primary molars. In the scenario given, both mandibular deciduous second molars are ankylosed. Treatment options are presented when the mandibular second premolars are present and when they are missing. Options of extracting the ankylosed deciduous molars and closing the space orthodondically are given as well as holding on to the
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Pocket Atlas of Dental Radiology


Friedrich A. Pasler and Heiko Visser
Publisher: Thieme Price: US$44.95 ISBN: 9781588903358/9783131398017

This pocket book is an English translation of a 2003 German text which was designed to assist undergraduate and postgraduate students, and practicing clinicians with aspects of dental radiology. The title of the book undersells its scope, since half of the text is devoted to radiographic pathology and half to radiographic technique, radiographic anatomy and image processing.

BOOK REVIEWS

The book follows an unusual format which is relatively information dense, with the left page containing text and the right page containing illustrations and images, with some 798 radiographs included. The tab is also colour-coded to allow ready reference to the various chapters. This somewhat unusual format proves very effective in being able to find information rapidly. The first half of the book begins with panoramic radiography and then moves on to intra-oral radiographs and then to skull films. Some coverage is provided of computed tomography and magnetic resonance imaging, although these sections of the book could certainly benefit from being expanded, given the increasing use of computed tomography in various aspects of contemporary dental practice. A specific section is devoted to determining the location of malpositioned teeth and this would be of considerable interest and relevance to practitioners with a strong orthodontic component in their practice. There is a short, but very up-to-date, discussion of radiographic film and conventional film processing and a good coverage of processing and film positioning errors. The text has a good coverage of digital systems and includes up-to-date information of both phosphor-plate and sensor systems with a useful discussion of both CMOS and CCD digital sensors. This section is followed by a short, but useful, discussion of radiation exposures with some useful reference tables. The remaining half of the book is devoted to diagnostic radiology, ranging from dental caries, periodontal and endodontic pathology, through to lesions of the jaws, maxillary sinsuses and temporomandibular joints. The useful section is included, devoted specifically to traumatology and an excellent section is included on the identification of foreign bodies. The quality of the images provided is routinely very high and the line illustrations are particularly well drawn. Numerous photographs of radiographic technique are included, which are upto-date and which address issues such as infection control. Numerous radiographs have detailed codes to identify particular aspects of radiographic anatomy and users at all levels of experience will find these particular useful. Overall, I found this a very well put together book, which has not suffered in any way from the process of translation. It is information dense, but in a way

which is useful, providing within a small number of pages, an intense coverage of a particular topic. Unlike a number of radiographic texts which are used in dentistry at the moment, the technical coverage of aspects of digital imaging is of very high quality and is remarkably up-to-date. The illustrations and diagrams are a particular strength of the book and clearly much effort has been expended to make these both very simple and also very realistic. This book will be of value to clinicians at all levels of experience and, while not designed to be an oral pathology text, provide a very useful coverage of all common and less common lesions that are likely to be encountered. I can see it getting intensive use by undergraduates and postgraduates, as well as being a ready reference to have on the shelf in clinical practice. Laurence Walsh

Applications of Orthodontic Mini-Implants


Jong-Suk Lee, Jung Kook Kim, Young-Choi Park and Robert L. Vanarsdall
Publisher: Quintessence Publishing 2007 Price: US$168.00 ISBN: 978-0-86715-465-8

This book is mandatory reading for all periodontists, surgeons and orthodontists who use or want to use the new technology called orthodontic miniscrew implants, also known as temporary anchorage devices or TADs. This technology is full of promise, but has often delivered disappointment. Many remedies are given in this book, which contains a complete knowledgebase up to 2007 on orthodontic mini-implants. It is a knowledgebase that began about seven years ago. Many of the studies cited are still pending publication in mainstream journals. Consequently, this book contains much new research and knowledge in the field of mini-implants. Its Korean authors are all orthodontic university professors, and are the scientists behind many of the studies cited. Their studies have refined the design theory and the protocols for use of TADs. The devices
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are very specialised and differ from implants designed for dental prosthetics. The initial chapters impart a complete education in the complex concepts involved in mini-implants, including, the principles of metal engineering, the histological and biological responses to the devices and protocols for the use of miniimplants. Previously unpublished anatomical considerations are illustrated using cadaver and 3D dental CT imaging research. Serious consideration of force vector relationships is fundamental to success when planning orthodontic mini-implants, and this topic is extremely well-covered. After reading only a few pages, I realised the folly of using any implants before fully digesting the whole text, and then I realised that these devices have many more applications than I previously thought. The book is very instructive in mechanotherapy generally. Many problems in clinical orthodontics are now problems we used to have because mini-implants have relegated them to the past. The paradigm shift is huge! Chapter 1 covers the evolution of nonintegrating mini-implants for temporary anchorage. This concept is totally different from the osseointegrated implants used for tooth prosthetics. There are 67 references at the end of this chapter. Chapter 2 deals with the biological principles, including: healing at the implant-tissue interface, differences in bone trauma and healing with pre-drilled and self-drilling implants and factors lessening survival of healthy tissue at the implant interface (127 references). Chapter 3 covers the mechanical design and operator handling of a mini-implant from its tip to its top, and how these factors bear on the success or failure of a mini-implant. For instance, why is there a difference in success between the right and left sides? This chapter has 63 references. Chapter 4 covers treatment planning, and is illustrated with cadaver crosssections. There are many, clear illustrations showing in great detail: suitable and unsuitable bones for mini-implants, the extent of the attached and free mucosa influencing the choice of site, the thickness of the mucosa and the many other hazards. We are led to conclusions about the proper choice of implant length, thickness, taper, transmucosal height and angulation. All possible sites of placement are very thoroughly discussed (32 references). Chapter 5 on 'Surgical procedures' explains the keys to obtaining a stable implant: implant handling, importance of proper hand tools, direct and indirect
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approaches, covered placement, length, diameter, angle, vibration, speed, cooling and loading. Also discussed are: pre-operative planning, appointment scheduling, grip of tools, posture, marking, predrilling, direct and indirect approaches, guiding, forces used, post-operative care and patient instruction, removal, loosening, fracture, periodontal injury, damage to teeth and soft tissues, pain, covering over, infection and choice of an inappropriate site (19 references). Chapter 6 on 'Mechanics' covers: the threedimensional movement of the dentition, how to avoid what used to be unwanted extrusive effects in conventional mechanics, how to effect what was previously difficult intrusion, effecting extrusion, implant positioning for proper force vectors, indirect use of anchors, force thresholds, possible orthopaedic effects, the advantage of using force-driven mechanics over shape-driven mechanics, how TADs extend Grabers classical envelopes of tooth movement, nonsurgical correction of vertical excess, whole arch distalisation to avoid extractions for moderate crowding and en masse arch movement to correct dental midline discrepancies. There are many case illustrations in this chapter (28 references). Chapter 7 reveals a novel paradigm that totally changes some orthodontic concepts. In 1900, Angles paradigm was of a static occlusion; in the 1980s and 1990s Proffits was of a soft and hard tissue environment limited by envelopes of tooth movement. Now TADs stretch all limits of previous envelopes of treatment. Loss of anchorage is no longer a limit; it does not exist. Molar intrusion by braces is easy, so that non-surgical treatment of severe open bite and gummy smiles is routine. Tooth displays (within the lip lines) can now be elevated or depressed, protracted, canted or retracted, and moved transversely or unilaterally without surgery. Our guides are now aesthetic, face-driven treatment goals in non-growing patients, and are no longer bound by the limitations that existed prior to skeletal anchorage. Occlusal planes can be tipped according to the aesthetic goals of treatment. Levelling can be planned for occlusion, A-P and transverse occlusal plane, for gingival margins and for healthy alveolar bone heights. Our VTO is now a much more detailed calculation, since we have better control of more variables. The chapter contains an excellent review of these principles and of smile aesthetics with many case illustrations (60 references).

BOOK REVIEWS

Chapter 8 details the new mechanical concepts needed for orthodontic appliances working in our new A-P anchorage paradigm. These include how to control tooth tip, torque, archform distortion and bowing, control of arch level and arch canting, bodily and en masse retraction and protraction of teeth, control of transverse and vertical bowing effects, midline deviations, molar distalisations and periodontal bunching problems. There is a detailed discussion of the force vectors needed for tooth movement. These vectors dictate the proper positioning of the mini-screws and lever arms. Inexperienced clinicians need to be cautious because with secure anchorage (compared with old paradigm mechanics) the wanted and unwanted tooth movements will be larger than without a mini-screw TAD. Typical issues include over retraction and over intrusion (implants are apical to the occlusal plane), plane canting, root resorption and pushing teeth out of the alveolar trough and out of attached mucosa (24 references). Chapter 9, 'Vertical control', demands a very detailed appreciation of the force vectors acting on teeth axes in all in three dimensions, as well as in the incisal A-P positions and occlusal planes. Archwires designed for tooth intrusion will normally extrude adjacent teeth (because much less force is needed for this), unless a mini-implant anchor is added to the system. The position of a TAD will influence the outcome. The efficiency of the mechanics varies with distance from a TAD to the target teeth. Force-driven mechanics work more efficiently than shape-driven mechanics, but the side-effects need to be controlled. Monitoring of the periodontium, root resorption, torque, tip, arch symmetry and facial change are important. Incisor extrusion without increasing the facial vertical dimension (formerly a difficult manoeuver) can now be achieved when implants bolster the anchor teeth. Control of incisor tipping (that accompanies intrusion - extrusion) must be planned into the mechanics. Molar intrusion is a three-dimensional exercise needing mindful control of the tilt of the occlusal plane, molar vertical position, molar tip and torque, molar axis, centre of rotation of the segment being intruded and the root areas of the teeth to be moved. All these things will be changed by intrusive forces from implants, so control needs to be planned. Single force intrusive vectors can be joined with continuous arch mechanics to help

cancel side-effects from each force system. Cross-arch splinting will control movement of the upper molar roots, but it reduces efficiency. Cross-arch splinting requires palatal and buccal implants and for both first and second molars to be splinted, but it prevents unilateral intrusion which needs its own type of special planning. Positioning an implant and force system as far posteriorly as possible is a key to successful control of the second molar palatal cusp and intrusion. Lower molar intrusion is especially difficult due to dense bone and limited sites for implants. Second molars need greater intrusion, but the bone in the area is often inadequate or inaccessible. Therefore, to control the second molars, indirect anchorage must be used with torque from the buccal. For controlling A-P tipping of an occlusal plane, two implants set apart are needed. Lingual mandibular implants are possible, but very difficult. Molar extrusion requires push mechanics off the implants. If used unilaterally this can correct occlusal plane canting (32 references). Chapter 10 discusses transverse control. Asymmetrical maxillary crossbite and scissor-bite are situations where mini-implants can assist by bolstering anchorage on the side needing expansion or contraction. Single force mechanics to individual or small groups of teeth that need uprighting are very effective (22 references). Chapter 11 covers preprosthetic orthodontic preparation. Mini-implants provide anchorage regardless of the condition of the dentition. This final chapter illustrates the usefulness of creating space for prostheses, for periodontal improvement and for alveolar bone augmentation through tooth movement. Miniscrew implants are especially useful for the precise control required of anchor teeth (12 references). This book is an exquisitely designed and illustrated assistant to the use of the new orthodontic miniimplant technology. It is a timely arrival because the technology is new and poorly understood by many in the profession. The technology promises good things, but unfortunately it has instead delivered much frustration to its users. Thankfully, remedies to many of the problems are given in this book. The book has two basic themes. The first is the biological, mechanical theory and material design concepts, which are based on considerable scientific and engineering knowledge. The second theme is the practical and clinical application of this knowledge. There are
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many high quality, detailed and annotated sketches and clinical photographs. It is also the best book on mechanotherapy I have read. The book illustrates the design concepts embodied in the 'Orlus' implant system exclusively, in which some of the authors may have a financial interest. This fact does not detract in the slightest from the value contained in the book. Although very high failure rates

are frequently reported, the authors claim very low failure rates when observing their principles and use of materials. It is a very significant contribution to the field of mini-implants. Geoff Wexler

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Interview

An interview with Milton Sims Part 2


Simon Freezer, Craig Dreyer and Wayne Sampson
The following is the continuation of an interview conducted with Milton Sims during 2000. Simon Freezer is in private practice in Adelaide and is a senior clinical tutor in orthodontics at the University of Adelaide, Craig Dreyer is senior lecturer in orthodontics at the University of Adelaide and Wayne Sampson holds the P.R. Begg Chair in Orthodontics at the University of Adelaide. Part I was published in the November 2006 issue of the Australian Orthodontic Journal.

When was your first trip to Japan?

My first trip to Japan was in 1969 en route to Europe. I stayed for a couple of days and gave my first lecture on the Begg technique at the Nippon (Japan) Dental College in Tokyo, when Kei Enoki was the Head and Kosuke Motohashi was the second-in-command.
Was this the first time that the Japanese had been introduced to the Begg technique?

I was not certain how I would be received during that first visit to Japan. The Japanese were a passive audience and Enoki was very nice. He had a strong western background and was the head of the department. He obtained his dental degree in America before WW I and had an interesting history because he was nearly interned during WW II. The Japanese authorities thought he was too pro-western as he could speak English very well and had many connections. Whenever I went back to Japan there was always a special dinner, often in conjunction with the Begg Society. Enoki always attended and I remember him telling me at one stage about the decision to lure me to Japan to teach. Enoki said that the Japanese had heard of me and had read Raleigh Williams publications. It was decided to ask me come to Japan because I worked with Dr Begg and, therefore, could explain the technique and its latest concepts. The Japanese were hungry for information and they would ask questions related to lectures and to previous courses and visits. When you gave lectures they would photograph all of your slides and tape record your talk. After the courses small study groups formed which re-examined everything that was said and everything that was shown. They were disciplined and they worked very hard.
Were the presentations in Japan aimed at orthodontic postgraduate students or for orthodontists?

No, it wasnt the first time the Japanese had encountered the Begg technique. I dont recall now, how it happened. I suppose it was probably after Dr Beggs publications in the American Journal of Orthodontics. The Japanese were very technology conscious and were heavily influenced by the Americans after WW II. Japan also had a long association with Germany because they saw the Germans as being very proficient mechanically and technically, as well as in chemistry. The Japanese would always seek the latest information and technology.
Did the Japanese see Australia at the cutting edge and want the latest information regarding the Begg technique?

Exactly. Enoki was keen to find out more and came to Australia, but I have forgotten the date of his first trip. I think it was after I went to Japan for the first time as I remember, I lectured and had lunch with him. It was rather funny. I was taken out, after I had been lecturing in the morning, to a meal of raw fish which I had never eaten before. After lunch I think I must have turned a very green colour and felt horribly ill. I was awfully embarrassed because I had to lie down for an hour and just couldnt move. However, the lectures had to go on and with thoughts of Australian pride I persevered, but it was a terrible experience.

For everyone! I think that the first course had about 80 participants. The course went for a week, and it was difficult lecturing to a Japanese group and so Enoki acted as an interpreter. At the end, he and I were physically and mentally exhausted because the course started at 8.00 am and finished at 6.00 pm. It
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was non-stop. We were required the entire time for teaching typodont work, lecturing, making and looking at archwires, reviewing mechanics, answering questions, giving seminars and drawing diagrams on the blackboard: the days invariably finished late. I would be taken back to the hotel and asked to be ready in 15 minutes to go out for dinner. It was pretty hard as all you wanted to do was to rest and get under a hot shower. Often the evening dinner did not finish until 1.00 am and you would go back to the hotel to unload all of the slides from the previous lectures and prepare for the next day. Because of the language problem, the presentations had to be visually intense and so there were a lot of slides to take away. Sometimes, you wouldnt get to bed until 2.00 am or 3.00 am. However, at the end of every course there was a final dinner. On these occasions, as at other large political meetings or formal receptions, a gold screen was usually erected. The gold screen in Japan means that it is an important and formal occasion. The formal course dinner would always be held at a top class hotel; in places like the Imperial Hotel or others nearby. The comfort of these hotels made up for the pain and stress of preparation. A good hotel was needed because it provided the facilities to get yourself going. Getting back to the gold screen, there was always one erected at the final dinners. At these dinners someone would sing, someone would write a poem or tell a funny story and then others were requested to go out to the front and perform. This is the Japanese karaoke. I cant remember if we ever had a piano there, but they used to do all sorts of things. I have lost track of the times that I had to sing Sakura. This is a traditional Japanese cherry blossom song and I would sing it after a couple of sake, which is a deadly drink. The traditional Japanese restaurants are pretty expensive particularly when geishas serve you. These girls were beautifully dressed and I remember once having so much sake that I thought that I would never be able to stand. It was terrible. You sit on the floor on a cushion for three hours like a yoga exponent without having any practice. Enoki told me that warriors did this when they returned from battle. The survivors would have a traditional dinner with the Daimyo (he was the prince or the leader) in his castle and be served by geishas. Of course the warriors would drink sake until
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Figure 1. Helen and Milton Sims on the day of Miltons investiture as an


Officer of the Order of Australia.

they passed out. Anyway, the geisha serving me at the final dinner was very nice and continued to pour me more sake. I told her that I should not have any more otherwise I could pose some social difficulties. She looked at me with understanding and, with a smile, told me not to worry. So for the rest of the evening we were on very good terms.
Did you do all of the presentations by yourself, or was there someone else from Adelaide to help?

In all of my visits to Japan I was the only presenter, but I travelled with my wife. I had to do it all because there were few others available at that time. It took months to prepare for the courses, and it would take ages to settle after arriving back home because there was a backlog of work to manage. The trips were organised by Enoki who arranged the fare and accommodation, which was a 5-star hotel. Helen and I were met at the airport by a chauffeur-driven limousine which drove us around and showed us the sights. We

INTERVIEW

were shown a great deal of Japan, but more particularly sights that westerners often didnt see, all due to the kindness of Enoki. We were taken to historical temples, we saw museums, art galleries, places where jewellery was made and even saw a Japanese wedding by chance. Enoki was with us on all but one of those trips, and they were really nice when you reflect on them.
Was this the time when you became interested in Japanese art?

I had no prior knowledge about Japanese art, but my interest started on my first visit. I asked one of Enokis staff from the college to take me back to a gallery (it was the one time Enoki wasnt with me). It was a very wet day and it was decided to go to a nearby print shop instead. I had not seen an extensive range of Japanese images before and I liked what I saw. The proprietor was eager for a sale and said that all of the artists were good. When I asked the price of the piece that I really liked, I was told A$500. I only had A$550 to get me to Europe and home again and so I decided to be discretionary. If I had bought that picture it would now be worth $100,000 and, in fact, you probably would not even get it for that price. That is how much Japanese art has appreciated in 30 years. That was my artistic chance, one of my artistic chances that I missed. On another occasion, we were taken to an inn near Kyoto. It was the most expensive inn in Japan where the royal family regularly visited. It was traditionally Japanese and it was my first experience of sleeping on a futon on the floor. In the corner of the room there was, what looked like, a wine barrel made of Japanese cedar with a lid. It was full of hot water and that was your bath. I put my hand in it several times and the water was almost boiling. I dont know how anyone could get in it. But, the food and the attention at the inn were all out of this world!
I gather that the visits to Japan were part of trips to Europe to give orthodontic lectures. How often did you travel overseas to provide courses, and what changes did you encounter?

ical field, so clinicians find it difficult to compete with full-time researchers. I admit that I became a little tired of being asked this question and replied that publications have absolutely nothing to do with professional standing, which dumbfounded my academic colleagues. I believe that there is only one measure of professional standing and that is the number of times you have been asked to travel overseas and address a meeting and/or give a course. That is the only criterion. Some recognition would be gained from writing papers, but in a clinical subject (unless you were asked overseas) a university school had little standing. If you consider the number of times that I went overseas and also appreciate the time in preparing for each trip, it would take many nights and weekends at home getting ready. A huge amount of material needed to be organised and I would take away 1500 slides at times, not just of theory, but records of treated cases. This resulted in a request to the university to provide me with a clinical camera. The university was not interested and declined and so I had to buy my own in order to obtain records to demonstrate patient treatment, otherwise you couldnt lecture. People had to be shown what you actually did.
During your visits to Japan, did you notice innovation or their own modifications to the Begg technique?

Well, many things that they tried had already been tried. The Fujita mushroom technique came out of Begg as an incidental. The Japanese were innovative and they tried different things, but I think that the major influence would have been Fujita because he took the Begg technique and applied it to the lingual.
When did he do that as I believe that multiple lingual orthodontic appliances were patented in Japan in 1976?

There are benefits in going away and giving a course. I enjoyed travelling and presenting and did it because I represented my country and also to help build credibility for the program in the university. People have often asked me about the number of papers that I have published. It is forgotten that dentistry is a clin-

I became aware in about 1975 that Fujita had started to experiment with lingual Begg and was trying to develop something quite different. Dr Begg expected me to rigidly adhere to the technique, because it became confusing for people if you talked about variations and improvisations without first having an understanding of the basics. A classic example of how this could happen was when I was asked to speak at the London congress in 1973. There was a group of translators converting my talk into Japanese. I said in
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Figure 2. Milton Sims with participants at the first Begg technique course in 1969.

my lecture that I thought it was wrong to tip the teeth back so far in the second stage of treatment and follow this with strong torquing auxiliaries. The teeth were tipped back and then tipped forward again and I felt that this was wrong and unnecessary. Two weeks after that congress I returned to Australia via Moscow and Tokyo. I spent about four days in Moscow and I arrived back in Adelaide whereupon Dr Begg was on the phone. Someone had sent him an airmail letter and he was ropable. He said that I was going against his teaching and he knew what was right. I do not think that he ever forgave me for deviating from his principles and offering my opinion. Dr Begg had his finger on the pulse and was always trying to oversee the development of the technique. People would write to him and suggest changes to mechanics because they had heard a lecture reporting beneficial effects. The Japanese were inclined to accept the technique and perfect it and I think that they realised that I was trying to give them the right information.
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On one particular course in Japan a curious and unfortunate thing happened. I was in the middle of a wire bending session on a Monday morning and the whole group was standing around me. A gentleman walked up and tapped me on the shoulder, excused himself and said that my house had burnt down. I just looked at him, said Thank you, and kept working. I thought that this was silly. He came and tapped me again and repeated the news that my house had burnt down. I asked him how he knew and he said that a message had been received from my wifes brother who tried to contact me in Tokyo. I was a bit shaken, but I continued working for about 15 minutes trying to focus on what I was doing. I finally rang my mother and she said that she saw it on TV. By that time, the news had spread and after a few days, all of the people in Adelaide had recognised the property and had been to see it. I had to arrange for a guard to be put on the house, to safeguard the little that remained.
When was this?

This was in 1973.

INTERVIEW

How did your wife take the news?

I decided not to tell Helen so that she continued to enjoy the trip. The course organisers were going to take us to Kyoto to sightsee and so I thought that I would keep quiet. I told her what had happened to the house when flying home from Japan. I remembered that particular year for many reasons. After the 1973 course, the Japanese started coming down to Adelaide in force and after the first year, Enoki brought a fabulous interpreter. In fact, this interpreter attended courses both in Australia and Japan until the last course I gave in Tokyo during the 1980s. I remember during a course one afternoon in Tokyo I told the interpreter that she might as well give the talks for the next hour because I was going to have a cup of tea. Her interpretive skills were so good that she almost knew what I was going to say next. She had heard me many times in Japan and again when they brought her down to Adelaide for update courses. She was expected to be the travel agent, mother confessor and do all of the organising above and beyond the call of an interpreter.
You used to have a little Polaroid camera for making slides. Is this what you used to prepare your lectures?

Polaroid lens and even with three-dimensional effects. Multicoloured slides could be made with nice titles and added graphs. Processes improved and became more sophisticated. Additional images could be scanned and coloured with a palette to make a multipictorial slide. Slides became more than just titles. Today, we have PowerPoint and the ability to make three-dimensional movies. Technology has brought us a long way.
When was the Begg heyday in Japan?

The heyday for Begg would have been in the 1970s. Begg was practised everywhere and we could never accommodate all the people who wanted to attend courses. There were always too many. It was curious because in those days, by government rule and regulation, there were no specialties in dentistry per se, as a Japanese dentist was expected to do everything. The people who came to the courses were not specialists, but were general practitioners who had a special interest in orthodontics. Enoki appreciated that the Begg technique was ideal for treating the typical Japanese malocclusion because it was protrusive with significant crowding. There were no anchorage problems that were often experienced with other techniques, and there were few bite opening issues. Extraction spaces could be easily closed and often you didnt need much torque because the teeth were so protrusive at the start. Enoki also mentioned that, even to this day, the Japanese do not like to undergo orthognathic surgery. There are a couple of clinicians, but one in particular, Dr Etsu Kondo who practises in Tokyo, is extraordinarily proficient in treating difficult skeletal Class III malocclusions with Begg. In fact, Kondo spoke at the ASO congress in Melbourne in 1996, but because there was a concurrent program she had competition in another hall. She showed some marvellous cases that many missed. The Begg technique is still being used in Japan and Europe, although its heyday has passed.
How have things changed in Japan?

In 1976, I purchased my first computer in London and a program for making slides. Prior to that I used to use cut-outs and photograph them. In America, we used to buy plaster letters with pins in them. You could get these in photographic shops and they were used for making movie titles. The letters were pushed into a pin board and then I would photograph them on Kodak film. Slides were made of paper cut-outs of teeth and I think that I still have a few of the cut-outs that I made in America. In the early days, magnets were put on them to show how teeth could move. This gained popularity and all presenters started doing it to show tooth movement. Gradually, the quality of slides kept improving and you always had to make them better to keep up with the trend. It was always a lot of work. The next trend was to tie slides together and photograph them and also to put a colour film over a black and white photograph. We graduated to use Letraset and photographed the slide text in black and white, which looked better than photography of typewritten letters. Eventually, slides could be made electronically and in colour with a

Things have changed in the same way that they have changed in America. When I first went to America they didnt know much about me, but because I was talking about the Begg technique, four or five hundred attended my lectures. I lectured about
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Figure 3. Participants at the 1977 course on the Begg technique in Japan.

anchorage control and the treatment of extraction cases. The Begg technique turned America upside down and the same thing happened in Japan. The Americans and Japanese found that unless they were proficient orthodontists there were problems in finishing. Kesling developed the positioner because of the finishing problems. The positioner became popular and a similar thing is happening now with the new invisible orthodontics; its really a modern Kesling positioner.
Do you have any thoughts on the evolution of orthodontic appliances?

cases 30 years out of treatment and they were quite incredible. I think that Peter Keslings adaptation of a straight-wire bracket, the cutting-off of opposite slot corners offered great potential for the edgewise people and I think for the Begg people too. It was a great step forward. At the time, the Begg technique was being isolated by practitioners who saw edgewise as a way to make life easier. Thats how it was marketed. When I went to private practice, I started to use TipEdge exclusively because it was hard to obtain at the Dental School. The brackets were more expensive than edgewise brackets, but I found that they worked well. A few Americans indicated that they used TipEdge brackets on canines because anchorage was not lost. They used the traditional edgewise concepts except on the canines. Dr Begg always said that was one of the major problem areas with extraction cases, as anchorage was lost in trying to get the canines back. The Keslings said that their greatest sales were to the edgewise practitioners who bought the TipEdge canine bracket. I found that if I didnt bracket and band my bicuspids until the last stage of treatment I could, with the Tip-Edge appliance, get the bite open and not lose anchorage. In fact, I think that I probably used the lightest torque possible on anterior teeth. I was using a 0.020 inch base arch (originally I used 0.022 inch wire but then I cut it back to 0.020 inch) and on that 0.020 inch I wound a

The world really does go around in orthodontics. Its gone back to Angles time and I dont believe that any orthodontist with any serious experience can argue against that claim. The bracket fundamentally is not any different from most straight-wire systems. The metal band has gone and the slot has been angulated. Dr Begg said that Angle had tried brackets with angled slots, but felt they were impractical. The world since Angles time has seen the bonding of attachments which have angulated bases or the angle of the slot on the face changed. It is still fundamentally an angled bracket with the same problems previously experienced by Angle. I think Tip-Edge based on the Sved bracket was a very smart move. The Sved bracket is like two Vs and in fact I met Sved once in New York. He showed me some of his non-extraction
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INTERVIEW

torquing arch that was usually 0.009 inch. Once I put that arch on, I did not have to remove it. It used to take me a while to prepare it and never alongside the patient. There was a simple reason for that. If you made one and you were almost through finishing it (remember 0.009 inch wire is not that easy to handle) and it broke, your appointment period for the session will be absolutely ruined. I always made the archwires and auxiliaries at home. I measured the distances between the canines and the incisors and, when the patients attended, I could simply attach the arches and dismiss them. I used very light Class II elastics, changed no more than once every five days. I closed extraction spaces with elastic chain and applied it stretched one link from molar to canine.
So thats four teeth that you stretched into three links?

Where was he from initially?

No, it would vary a little depending on where the hooks were placed on the lingual of the molar and a bonded button on the canine. The distance on a closed piece of chain may have been six links from hook to hook and that was stretched to five links.
So this is on the lingual?

Yes, on the lingual so it couldnt be seen. I would measure how much chain I would need and stretch it one link and put it on. If space opened, torque was too strong. I used to show this overseas and it was misunderstood. In fact, I had one of my cases transfer to Canada. I set the patient up and made the referral, but the patient came back 12 months later and I had more work to do because a torquing auxiliary was placed that was far too strong. It was so strong that half of the extraction space had opened up. That excessive amount of torque was being taught in the States. I treated the mother of this patient at the dental school almost 30 years earlier. She had early Begg therapy and she still has a great dentition.
Was part of the problem the pre-formed auxiliaries that were being made?

I think that is what happened. Raleigh Williams was a great operator in both edgewise and Begg. I think he was still working with edgewise concepts in the back of his mind. His torquing archwires had a very strong action.

I think that Raleigh was from Chicago and was, in fact, one of the tutors at the Tweed course. He and Kesling were both tutors. To be a tutor there you had to have the seal of approval from Charlie Tweed. Do you know that Tweed was like Begg? Tweed presented the same attitude and approach to treatment via a different mechanism, but he was after the same result as Begg. I am guessing here but you have to try and look behind the scenes. The first thing you need to realise is that Bob Ricketts was trained by Brodie at Chicago. Brodie, for the whole of his practising life was an Angle disciple, therefore, a nonextraction adherent. After Brodie retired from Illinois, Frans van der Linden asked him over to Nijmegen where he taught students nonextraction mechanics. When I was on a trip to Holland I remember being asked out to dinner and speaking to one of the van der Lindens students. We had a very interesting conversation. I asked how his cases were going and he said that some of the nonextraction cases will hold up and some of them wont. Brodie was always nonextraction in his school, but Ricketts was not totally nonextraction. Ricketts wasnt going to copy Begg, but was going to try and get around the extraction dilemma. He was smart enough to realise that edgewise mechanics in those days couldnt effectively open the bite. This was why segmented arches and intrusion arches became popular with those who wanted to have the best of both worlds. In Japan, the tendency was to follow what was happening in America and their American connections were very strong. I think that there are some very top rate orthodontists in Japan. One thing I havent told you is that there were two Begg groups in Japan. There was the Enoki group in Tokyo and the Kameda group in the Nigata branch of Nippon Dental University. The Begg Society was formed by Enoki and my last visit in 1997-1998 was the farewell meeting of the Tokyo Begg Society. It was fortunate because I nearly didnt go. The Tokyo Begg Society arranged this final trip and indicated that two business class tickets would be provided for Helen and me. I thanked them and agreed to go, but a little later the deal was renegotiated. A lesser amount was offered which wasnt going to buy me a single economy fare and pay for accommodation and so I declined. The Society renegotiated for
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INTERVIEW

business class fares and three days accommodation to which I agreed and went up there and spoke. At that time Enoki was very sick and they asked me if a video could be made to send to him. However, I am still in contact with Kameda and receive his journal of publications which show excellent treatments. He is now leading the Begg movement in Japan, although some have moved away from the technique. I have a feeling that you have to have someone leading the charge like TP rely on Richard Parkhouse. Richard is marvellous, but it is pretty hard to be a one-man band. Perhaps you can imagine the overseas travel and the efforts to keep courses going. Leading the Begg charge in the early days was a pretty big thing and it was hard on my family. Few people appreciated the time and commitment involved. I think if we are going to ever get the answer to your question about what is happening in Japan, we will have to go back to Kameda. My guess is the Begg technique will last as long as Kameda, as long as he is at his University. He was young when he started, but he must be getting towards the end of his term. He would be nearly 65 years of age and, usually, retirement age is 65. In Japan, the universities are highly competitive and Enoki, when I went over there for the first time, was president of the Japanese Orthodontic Society. He was of some importance. Before he died, he was made an honorary life member of the International Association for Dental Research in Japan and was a person of high esteem. He ran the big dental complex at

Nippon Dental University in Tokyo, which was one of the major schools in the country. The other one was Tokyo Medical and Dental School and Fujimori became its Head. Tokyo had a medical attachment and now there is the first department and the second department of Oral Biology and, therefore, the first and second departments of orthodontics. It is so large and the government provides finance. The schools asked me up there at minimal cost because the government provided tax relief for courses. It is a bit like Europe. It is said that Europeans pay more tax than Australians. This is probably true, but how do you think that the Europeans buy their boats to have on the canals in Sweden, Holland and Denmark? Because these are allowable tax deductions! It would be good if the mortgage on your house was tax deductible as it is in Holland. That is why they do so well. I went to the University of Utrecht when it was a magnificent new school in 1980. I have not seen anything to rival it in Australia. The facilities and the teaching laboratories were superb. The beautiful clinics for teaching were highly sophisticated, funded and coordinated. In the entrance hall there was a museum of dental items going back to the 14th and 15th century. In an open foyer as you entered there were restored old dental clinics. Things have certainly changed. The authors are indebted to Helen Sims for her helpful advice and clarification of places and names.

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Recent publications

Abstracts of recently published papers reviewed by the Assistant Editor, Craig Dreyer

Management of tooth resorption


G.S. Heithersay

and is mandatory reading for those who practice dentistry.


Australian Dental Journal Supplement 2007; 52: S10521

Root resorption has been a concern to orthodontists for over a hundred years. This timely article reviews the diagnosis and management of root resorption and offers an alternative classification. The wellused classification provided by Andreasen in 1970 in which resorption is divided into external and internal types is limited in its application, and does not cover the range of possible aetiologies. The articles suggested alternative classification of resorption comprises three categories, namely a) trauma-induced, b) infection-induced and c) hyperplastic resorption and provides a more comprehensive classification based on aetiology. The sections on infection-induced and hyperplastic root resorption are excellent reviews of the current status of endodontic management of these conditions. Although written for the general dental practitioner, the information is essential for the specialist who encounters resorptive pathology in the orthodontic assessment and management of patients. Tooth resorption related to orthodontic treatment falls into the category of trauma-induced resorption which is subdivided into a) surface, b) transient apical internal, c) pressure, d) orthodontic and e) replacement resorption. The placement of an orthodontic force on a tooth has the potential to cause tooth resorption, but pressure from other external agents (e.g. a developing tooth) also provides the possibility of root damage. The author explains that the removal of the pressure usually controls the situation. The problem of replacement resorption holds particular concern for the orthodontist who then has to clinically deal with the problem of ensuing permanent tooth ankylosis. A range of options is provided depending on the speed of the replacement and the circumstances of the affected tooth. This article neatly summarises the current understanding and management of root resorption

Frictional properties of aesthetic brackets


C.A. Reicheneder, U. Baumert, T. Gedrange, P. Proff, A. Faltermeier and D. Muessig

Previous studies on the frictional resistance of aesthetic (ceramic) brackets have invariably found a higher level of resistance with most archwires tested. However, does this apply to self-ligating aesthetic brackets? The authors set out to test the frictional properties of two popular self-ligating aesthetic brackets against four conventionally ligated aesthetic brackets. Because of the need for sliding mechanics, an upper premolar bracket with a 0.022 inch channel, according to the Roth prescription, was selected from several manufacturers and a number of rectangular archwires of differing dimensions and materials were examined. Frictional values were recorded using a Zwick testing machine in which each bracket/archwire combination was tested 10 times with new brackets each time. In addition, one manufacturers brackets were aged prior to frictional testing by placement in a chewing simulator, which replicated masticatory cycles and temperature changes occurring in the oral cavity. Appropriate statistical analysis was applied. The results indicated that one manufacturers brackets were significantly superior to all others. The particular brackets required the lowest frictional forces in all wire dimensions and qualities. The aged brackets possessed higher resistance values compared with new brackets indicating that bracket wear and tear increased resistance to sliding. The article was an endorsement of aesthetic selfligating brackets, but comparisons with stainless steel brackets would have completed the investigation. In addition, confusion still exists between friction and binding as friction is used to encompass both terms.
European Journal of Orthodontics 2007; 29: 35965

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RECENT PUBLICATIONS

Cost-effectiveness and patient satisfaction: Hawley and vacuum-formed retainers


L. Hichens, H. Rowland, A. Williams, S. Hollinghurst, P. Ewings, S. Clark, A. Ireland and J. Sandy

Over the past 10 years there has been a significant increase in the use of vacuum-formed retainers rather than the more conventional acrylic and wire varieties. Is this change more cost-effective for an orthodontic practice? The authors examined this question by comparing National Health Service and orthodontic practices in regional England and patient satisfaction with the various appliances. This was achieved via a satisfaction questionnaire completed while the patients were waiting for their retainer check 3 and 6 months into retention. Clinical effectiveness of the appliances was judged by a change in maxillary and mandibular incisor alignment over the six-month retention period, while a cost analysis was based on influencing factors such as: initial cost of the retainers, clinical time, laboratory costs, replacement retainers plus data related to each patients time and travel. Results indicated that patients preferred the vacuum-formed retainers because of better aesthetics and speech, in addition to fewer breakages. There was no difference in the level of discomfort. Vacuum-formed retainers stabilised the teeth better than acrylic and wire retainers, and were more cost-effective from the practice and the patients perspectives. The study concluded that patients and clinicians preferred vacuum-formed retainers because of their cheapness, compatibility and effectiveness.
European Journal of Orthodontics 2007; 34: 11327

Bands for decontamination were placed in an ultrasonic cleaning bath for 15 minutes. Subsequently, all bands were placed in phosphate-buffered saline and assayed by enzyme-linked immunosorbent assay (ELISA) for albumin, and also to detect the presence of blood and salivary amylase. Although there was a reduction in the amounts of amylase, 50 per cent of the decontaminated bands showed detectable amounts of protein, but the quantity of albumin was not statistically significant. After decontamination, bands would have been placed in an autoclave to complete the cleaning/sterilising cycle, but the authors question the effectiveness of the sterilisation given the unclean nature of many of the bands. The authors concluded that ultrasonic cleaning of trialfitted molar bands was not completely effective or efficient, and other means of cleaning organic material from appliances should be investigated.
Journal of Orthodontics 2007; 34: 1824

Elective orthognathic treatment decision making: a survey of patient reasons and experiences
J. Stirling, G. Latchford, D.O. Morris, J. Kindelan, R.J. Spencer and H.L. Bekker

Decontamination of orthodontic bands following size determination and cleaning


P.E. Benson and C.W.I. Douglas

Orthodontic molar bands are expensive and are reused after unsuccessful trial fitting during a patient banding. Wrong-sized bands are cleaned and sterilised for reuse, but how effective is the decontamination process? This was the question that the authors attempted to assess. Thirty-two patients had a band trial-fitted to each first permanent molar, which provided a sample of 128. Bands were randomly assigned to decontamination or no decontamination groups with additional unused/unfitted bands tested to determine baseline contamination.

Why do patients embark on an orthognathic surgical treatment plan? After all, orthognathic procedures are elective and should not be entered into without careful consideration. The malocclusions that this type of surgery manages are seldom life threatening, yet patients risk complications and morbidity by undertaking these procedures. The question was asked by the authors who answered it by conducting a crosssectional survey of patients who were making, or had made, a surgical treatment decision in an 1842 month period prior to the study in 2003. Questionnaires assessed patient demographics, dental history and psychopathology, and follow-up interviews explored patients reasons for, and experiences of, orthognathic treatment. Of the 138 patients approached, only 61 participated, whose mean age was 25 and, of whom, two-thirds were female. While psychopathology scores were within normal range, the interview analysis indicated that patients entered orthognathic surgery to improve their bite as well as to regain a more normal facial appearance. Patients reported that they were provided with enough service information, but the risks and benefits of the surgery were poorly explained. The survey revealed that

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RECENT PUBLICATIONS

patients possessed strong emotions regarding their facial appearance and the surgery that they received, but current practice did not satisfy their psychological needs and, in some instances, made them feel worse and undervalued. Furthermore, orthognathic patients did not appear to be making informed decisions regarding their surgical treatment. Clinicians needed to be aware of the psychology of their patients as many had unmet needs in relation to their decision making, and the emotional effects relating to treatment. The study concluded that, in addition to focussing on the psychopathology of patients, measures should be considered for the improvement in the patients emotional, social and functional well-being.
Journal of Orthodontics 2007; 34: 11327

Oral health benefits of orthodontic treatment


D.J. Burden

What are the benefits of orthodontic treatment? It has been considered that orthodontic treatment has provided oral health-related benefits apart from the cosmetic and psychosocial improvements that patients seek. In order to answer the question the author conducted a review of the literature to find evidence of oral health benefits. The results of the literature search indicated that claims of reduced susceptibility to dental caries, periodontal disease, temporomandibular disorder and traumatic dental injury could not be supported. The author contends that the oral health benefits of orthodontic treatment are limited.
Seminars in Orthodontics 1007; 13: 7680

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In appreciation
Reviewers for the Australian Orthodontic Journal

Over the past five years the following individuals have generously contributed their time, knowledge and expertise reviewing articles for the Journal. We sincerely thank them and acknowledge their considerable contributions which have improved the quality of the Journal.

George Anka, Tokyo, Japan David Armstrong, Sydney, NSW Theo Baisi, Sydney, NSW Saeed Banabilh, Kelantan, Malaysia Matthew Barker, Wellington, New Zealand Andrew Barry, Wollongong, NSW Peter Barwick, Auckland, New Zealand Derek Barwood, Auckland, New Zealand Joseph Bleakley, Biggera Waters, Q James Bokas, Burwood, Vic Karen Brook, Auckland, New Zealand Darryle Bowden, Cape Schanck, Vic Jay Bowman, Michigan, USA Peter Brockhurst, Mt Beauty, Vic Barbara Carach, Ringwood, Vic Ismail Ceylan, Ataturk, Turkey Mujalin Chawengchetta, Khon Kaen, Thailand Jonathan Chi, Castle Hill, NSW Peter Cistulli, Sydney, NSW Anthony Collett, Ferntree Gully, Vic John Coolican, Chatswood, NSW Rhonda Coyne, Cairns, Q Edward Crawford, Melbourne, Vic Marguerite Crooks, Christchurch, New Zealand Ali M. Darendeliler, Sydney, NSW Saxton Dearing, Napier, New Zealand Craig Dreyer, Adelaide, SA Bernadette Drummond, Dunedin, New Zealand Stephen Duncan, Sydney, NSW Peter Dysart, Dunedin, New Zealand Theodore Eliades, Nea Ionia, Greece Ray Enlow, Dunedin, New Zealand Mark Ewing, Hamilton, New Zealand Carlos Flores-Mir, Alberta, Canada Kelvin Foong, Singapore Peter Fowler, Christchurch, New Zealand Elissa Freer, Brisbane, Q Terry Freer, Brisbane, Q John Fricker, Manuka, ACT David Fuller, Brighton, Vic Joseph Geenty, Fairy Meadow, NSW Keith Godfrey, Sutherland, NSW Mithran Goonewardene, Perth, WA Urban H agg, Hong Kong, P.R. China Roger Hall, Toorak, Vic Patrick Hannan, Warana, Q Winifred Harding, Dunedin, New Zealand James Hartsfield, Indianapolis, USA

Michael Hase, Melbourne, Vic James Hawkins, Sydney, NSW David Healey, Dunedin, New Zealand Andrew Heggie, Melbourne, Vic Peter Herbison, Dunedin, New Zealand Christopher Ho, Brisbane, Q Kip Homewood, Berwick, Vic Douglas Holborow, Dunedin, New Zealand Jan Huggare, Huddinge, Sweden Nigel Hunt, London, United Kingdom Chung-Ju Hwang, Seoul, Korea Michael Hyde, Canberra, ACT Hideki Ioi, Fukuoka, Japan John Jenner, Adelaide, SA Lysle Johnston, Michigan, USA Malcolm Jones, Cardiff, Wales Andrew Kalafatas, Booragoon, WA Sanjivan Kandasamy, Midland, WA Chia-Tze Kao, Taichung, Taiwan, Republic of China Byron Kardachi, Adelaide SA Thomas Kardos, Dunedin, New Zealand Petrina Kat, Campbelltown, SA Heather Keall, Auckland, New Zealand Martin Kean, Geraldine, New Zealand Peter Keay, Sunnybank, Q Om Kharbanda, Mumbai, India Jules Kieser, Dunedin, New Zealand Russell Kift, Maitland, NSW Vincent Kokich, Tacoma, USA Anne Marie Kuijper-Jagtman, Nijmegen, The Netherlands Mark Kum, Christchurch, New Zealand Robert Kusy, Chapel Hill, NC, USA Stephen Langford, Adelaide, SA Brian Lee, Hobart, Tas Gavin Lenz, Brisbane, Q Kerry Lester, Sydney, NSW Peter Lewis, Gordon, NSW Russell Lovatt, Christchurch, New Zealand Andrew Lush, Nelson, New Zealand Randal McAlister, Auckland, New Zealand Fraser McDonald, London, United Kingdom Patricia Medland, Benowa, Q William Medland, Benowa, Q Murray Meikle, Singapore Christopher Miles, Clifton Hill, Vic Peter Miles, Caloundra, Q Steven Moate, Forestville, NSW Kylie Moseling, Burwood, Vic

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IN APPRECIATION

John Muir, Auckland, New Zealand Colin Nelson, Chermside, Q Richard Olive, Brisbane, Q Richard Oliver, Cardiff, Wales John Owen, Midland, WA Hyo-Sang Park, Deagu, Korea Sheldon Peck, Boston, USA Edward Peel, Sydney, NSW Neil Pender, Liverpool, United Kingdom Andrew Pepicelli, Murrumbeena, Vic Angela Pierce, Adelaide, SA Neil Pinto, Wagga Wagga, NSW David Plunkett, Chester, UK Shari Prove, Redcliffe, Q Andrew Quick, Dunedin, New Zealand Michael Razza, Perth, WA Marie Reichstein, Adelaide, SA Sheena Reilly, Melbourne, Vic Lindsay Richards, Adelaide, SA Stephen Richmond, Cardiff, UK Christopher Robertson, Dunedin, New Zealand David Rogers, Perth, WA Isao Saito, Nigata, Japan Richard Salmon, Adelaide, SA Wayne Sampson, Adelaide, SA Jonathan Sandy, Bristol, UK Mark Savage, Wanganui, New Zealand Andrew Savundra, Willerton, WA Paul Schneider, Melbourne, Vic Michael Schulze, Auckland, New Zealand Peter Scott, Melbourne, Vic Steven Scott, The Gap, Q William Shaw, Manchester, United Kingdom

Tracey Shell, Moonee Ponds, Vic Milton Sims, Adelaide, SA Shanti Sivaneswaran, Westmead, NSW Kirsty Skidmore, Bristol, United Kingdom Lesley Snape, Christchurch, New Zealand Steve Soukoulis, Adelaide SA Jane Spark, Sydney, NSW Robert Stallworthy, Wellington, New Zealand Antony Stankevicius, Launceston, Tas Pamela Stevenson, Cardiff, Wales Anthony Sutton, Mackay, Q Michael Swain, Dunedin, New Zealand Kazuto Terada, Niigata, Japan Guilherme Thiesen, Florianpolis, SC, Brazil Murray Thomson, Dunedin, New Zealand Andrew Toms, Adelaide, SA Grant Townsend, Adelaide, SA Colin Twelftree, Adelaide, SA Vicki Vlaskalic, San Francisco, CA, USA Hilton Wasilewsky, Woollahra, NSW William Weekes, Gosford, NSW Anthony Weir, Corinda, Q Geoffrey Wexler, Toorak, Vic Gregory White, Hawthorn, Vic Samuel Whittle, Canberra, ACT Peter Wilkinson, Broadbeach Waters, Q Matthew Williams, Wellington, New Zealand Michael Woods, Melbourne, Vic Pamela Wong, Alexandra Hills, Q Masaru Yamaguchi, Chiba, Japan Daxter Yeo, Aspley, Q Bjorn Zachrisson, Oslo, Norway

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New

products

Dentyl 2-phase formula mouthwash


Dentyl pH mouthwash is now available in Australia. This 2-phase oil-water mouthwash containing cetylpyridinium chloride helps fight bacteria, bad breath and plaque, according to the manufacturers. Available in Smooth Mint and Refreshing Clove, it is alcohol-free to reduce stinging and burning. To receive a free sample call Key Pharmaceuticals on 1800 653 373 For further information contact Symbion Dental Tel: 1800 888 262 Website: www.dentylph.com.au

VectorTAS
Ormcos new VectorTAS temporary anchorage system is a coordinated system of miniscrews, attachments and instruments designed specifically for orthodontics. VectorTAS provides TAD-specific auxiliary attachments and protocols to simplify treatment mechanics and to facilitate placement and utilisation of temporary anchorage, according to the manufacturers. For further information contact Ormco Pty Limited Tel: 1800 023 603 NZ 0800 446 140

Bendistal pliers
Bendistal pliers from Ortho Organizers are specifically designed to bend nickel titanium archwires. A simple intraoral adjustment using the V-Bend technique cinches the wires without annealing or twisting. The pliers can be used to place permanent bends in ligated archwires, according to the manufacturers. For further information contact Ortho Organizers Tel: 1800 645 813 NZ 0800 440 883 Website: www.orthoorganziers.com.au

Anterior Contraster set


According to Ortho Organizers, the Anterior Contraster set assists in presentation of quality slides and prints. They are made of anodised aluminium and can be autoclaved. The handles are conveniently shaped so that patients can hold them in place. Autoclavable only (no cold sterilization). Adult and child sizes are included in the set. For further information contact Ortho Organizers Tel: 1800 645 813 NZ 0800 440 883 Website: www.orthoorganziers.com.au

Occlusal Contrasters
The Ortho Organizers Occlusal Contraster is designed to simplify occlusal mirror views, and prevent lips, nostrils and moustaches from appearing in the photograph, according to the manufacturers. The other end can be used to black-out the background in lateral photos. Autoclavable only (no cold sterilisation). Available in adult and child sizes. Sold individually or in a set. For further information contact Ortho Organizers Tel: 1800 645 813 NZ 0800 440 883 Website: www.orthoorganziers.com.au 182
Australian Orthodontic Journal Volume 23 No. 2 November 2007

New products are presented as a service to our readers, and in no way imply endorsement by the Australian Orthodontic Journal.

Orthodontic

calendar

2008
February 1215 Federation of Orthodontic Associations of Central America and Panamanian Orthodontic Society XCI Congress, Sheraton Hotel, Panama City, Republic of Panama. March 15 21st Australian Society of Orthodontists Congress, Gold Coast Convention and Exhibition Centre, Gold Coast, Queensland, Australia. Theme: State of the art state of the science. Email: info@aso08.com.au Website: www.aso08.com.au March 58 Asociacin Mexicana de Ortodoncia 41st Annual Session, Hotel Camino Real, Tijuana, Mexico. Website: www.tijuana2008.com March 2830 6th Asian Pacific Orthodontic Congress of the Asian-Pacific Orthodontic Society, Shangri-la Hotel, Bangkok, Thailand. Email: apoc2008@gmail.com Website: www.apoc2008.com April 1213 10th International Symposium of the Greek Orthodontic Society, Titania Hotel, Athens, Greece. Email: info@grortho.gr Website: www.grortho.gr May 7 Australian Society of Orthodontists Victorian Branch Half Day Meeting. Part I: Infection control in the orthodontic setting. Part II: Medical emergencies and CPR. Email: tonycol@netspace.net.au May 911 British Orthodontic Society Spring Meeting, Celtic Manor, Nr Newport, S Wales. Website: www.bos.org.uk May 911 Societ Italiana di Ortodonzia & Socit Franais de Orthopdie Dentofaciale Mediterranean Orthodontic Integration Project. Theme: Efficiency, timing and the future in Orthodontics. Palazzo del Casino, Venice-Lido, Italy. Website: www.venice-sido-sfodf-moip.com May 1620 American Association of Orthodontists Convention and 108th AAO Annual Session, Colorado Convention Center, Denver, Colorado, USA. Website: www.aaomembers.org/mtgs/annual/2008

June 1014 84th Congress of the European Orthodontic Society, Lisbon, Portugal. Website: www.eos2008.com June 2325 Thai Association of Orthodontists Scientific Meeting. Theme: Interdisciplinary treatment. Bangkok, Thailand. Website: www.thaiortho.org August 2730 XII Congreso Internacional de Ortodoncia of the Chilean Orthodontic Society, Casa Piedra Convention Center, Santiago, Chile. Website: www.sociedadortodonciachile.org September 1113 60th Annual Scientific Meeting of the Canadian Association of Orthodontists, Delta Winnipeg Hotel, Winnipeg, Manitoba, Canada. Website: www.cao-aco.org September 1417 British Orthodontic Society Conference, Brighton, United Kingdom. Website: www.bos.org.uk September 2427 FDI Annual World Dental Congress, Stockholm, Sweden. Website: www.fdiworldental.org September 2729 1st World Implant Orthodontic Conference and 7th Asian Implant Orthodontic Conference, Seoul, Korea. Website: www.wioc2008.com October 1618 XII International Symposium on dentofacial development and function of the Egyptian Orthodontic Society, Cairo, Egypt. Website: www.dfdfcairo.com December 1314 Taiwan Association of Orthodontists 21st Annual Conference, Taipei, Taiwan. Website: www.ao.org.tw December 1921 43rd Indian Orthodontic Conference, Mumbai, India. Website: www.434rdioc.org

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CALENDAR

2009
May 15 American Association of Orthodontists Convention, Boston Convention Center, Boston, Massachusetts, USA. June 914 European Orthodontic Society Congress, Finlandia Hall, Helsinki, Finland. Website: www.eos2009.fi September 25 FDI Annual World Dental Congress, Singapore Website: www.fdiworldental.org September 1012 Canadian Association of Orthodontists 61st Annual Scientific Meeting, Grand Okanagan Lakefront Resort and Conference Centre, Kelowna, British Columbia, Canada. Website: www.cao-aco.org

2010
February 69 7th International Orthodontic Congress and 4th Meeting of the World Federation of Orthodontists, Sydney, Australia. Website: www.wfosydney.com

Please direct all meeting queries for inclusion in the calendar to Dr Tony Collett Tel: (+61 3) 9756 0519 Email: tonycol@netspace.net.au

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Index to Volume 23

The Australian Orthodontic Journal

Author index
Abdel-Kader H, 30, 157 Amoah G, 36 Anka G, 137 Armstrong D, 96 Balalaie A, 46 Banabilh S, 89 Bernab E, 50, Borges-Yez, 50 Carels C, 121 Cerny R, 24 Chan HJ, 55 Closs L, 41 Cozzani M, 109 Darendeliler M Ali, 96 Dinsuhaimi S, 89 Ferreira M, 130 Ferreira R, 130 Flores-Mir C, 50 Godfrey K, 65 Goonewardene M, 16 Gracco A, 109, 147 Harkness M, 76, 114, 153 Heravi F, 104 Herbison P, 114, 156 Ho CT, 1, 8, 79 Jones SP, 36 Kachiwala VA, 72 Kajan ZD, 46 Kalha A, 72 Kandasamy S, 16 Kraikosol K, 65 Kravchuk O, 1, 8 Lee B, 155 Ling K-K, 1, 8 Luca L, 109, 147 Moazzami SM, 104 Nasab NK, 46 Olive R, 1, 8 Petocz P, 96

Quirynen M, 121 Rattanayatikul C, 65 Raveli D, 41 Rsing C, 41 Sharp C, 114 Shen G, 96 Siciliani G, 109, 147 Singh GD, 89 Squeff K, 41 Stella D, 55 Suzina AH, 89 Synnott P, 78 Tahmasbi S, 104 Tennant M, 16 Teughels W, 121 van Gastel J, 121 Vattraphudej T, 65 Vigneshwaran J, 72 Woods M, 55

Oral Cavity Reconstruction, 161 Radiographic Cephalometry: From Basics to 3-D Imaging. Second Edition, 162 Tip-Edge Plus guide. 6th Edition, 163 Clinical Problem Solving in Orthodontics and Paediatric Dentistry, 164 Pocket Atlas of Dental Radiology, 164 Application of Orthodontic MiniImplants, 165
Bone-plate screw

Treatment of skeletal 2 malocclusion using bone-plate anchorage. A case report, 65


Brackets

Accuracy of bracket placement by orthodontists and inexperienced dental students, 96 Static frictional resistances of polycrystalline ceramic brackets with conventional slots, glazed slots and metal slot inserts, 36
Camouflage treatment

Subject index
Adult treatment

Treatment of a Class I deep bite malocclusion in a periodontally compromised adult, 130


Airway

Treatment of skeletal 2 malocclusion using bone-plate anchorage. A case report, 65


Case reports

Cranial base and airway morphology in adult Malays with obstructive sleep apnoea, 89
Aesthetic

Comparison of surgical and non-surgical methods of treating palatally impacted canines. II Aesthetic outcomes, 8
Book reviews

Treatment of skeletal 2 malocclusion using bone-plate anchorage. A case report, 65 Space closure using the Hycon device. A case report, 72 Treatment of a Class I deep bite malocclusion in a periodontally compromised adult, 130 Use of miniscrews as temporary anchorage devices in orthodontic practice. II Case reports, 137 Molar distalisation with skeletal anchorage, 147

Risk Management in Orthodontics: Experts Guide to Malpractice, 78 Colour Atlas of Dental Hygiene Periodontology, 79 Skeletal Anchorage with Microimplants, 161

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185

INDEX

Casein phosphopeptides

Dental caries

Gingival recession

Effect of Topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study, 46


Ceramic brackets

Effect of Topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study, 46


Dental changes

Lower intercanine width and gingival margin changes. A retrospective study, 41


Hycon device

Static frictional resistances of polycrystalline ceramic brackets with conventional slots, glazed slots and metal slot inserts, 36
Class II division 1 malocclusions

Vertical changes in treated and untreated Class II division 1 malocclusions, 114


Dental plaque

Space closure using the Hycon device. A case report, 72


Impact

Treatment of skeletal 2 malocclusion using bone-plate anchorage. A case report, 65 Vertical changes in treated and untreated Class II division 1 malocclusions, 114
Comment

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Distal screw appliance

The impact of orthodontic treatment on normative need. A case-control study in Peru, 50


Intercanine width

Molar distalisation with skeletal anchorage, 147


Distalistion

Lower intercanine width and gingival margin changes. A retrospective study, 41


Interdental papilla

Why would anyone be interested in measurement error? 156 When should we finish with a Class I molar relationship? 157
Cone beam computerised tomography (CBCT)

Molar distalisation with skeletal anchorage, 147


Editorial

Changes in interdental papillae heights following alignment of anterior teeth, 16


Interview

Forty years of publication, 76 What is a minimal clinically important difference? 153


Enamel caries

An interview with Milton Sims, Part 2, 169


Lateral cephalometric

Assessment of palatal bone thickness in adults with cone beam computerised tomography, 109
Contact relationships

Effect of Topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study, 46


Face height

Sella turcica bridges in orthodontic and orthognathic surgery patients. A retrospective cephalometric study, 30
Letter

Force and tooth movement, 155


Long term outcomes

Changes in interdental papillae heights following alignment of anterior teeth, 16


Cranial base

Vertical changes in treated and untreated Class II division 1 malocclusions, 114


Fibre reinforced composites

Cranial base and airway morphology in adult Malays with obstructive sleep apnoea, 89
Crossbite

Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1
Lower retainers

Fracture characteristics of fibre reinforced composite bars used to provide rigid orthodontic dental segments, 104
Finite element morphometry (FEM)

The reliability of bonded lingual retainers, 24


Miniscrew

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Crowding

Cranial base and airway morphology in adult Malays with obstructive sleep apnoea, 89
Fixed lingual retention

Assessment of palatal bone thickness in adults with cone beam computerised tomography, 109 Use of miniscrews as temporary anchorage devices in orthodontic practice. II Case reports, 137 Molar distalisation with skeletal anchorage, 147
Morphometrics

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Deep bite malocclusion

The reliability of bonded lingual retainers, 24


Fracture load

Treatment of a Class I deep bite malocclusion in a periodontally compromised adult, 130

Fracture characteristics of fibre reinforced composite bars used to provide rigid orthodontic dental segments, 104

Cranial base and airway morphology in adult Malays with obstructive sleep apnoea, 89

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INDEX

Obituary

Thomas Graber, 160


Occlusion

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Outcomes

Pocket depth

Comparison of surgical and non-surgical methods of treating palatally impacted canines. II Aesthetic outcomes, 8
Open gingival embrasures

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Pulpal responses

Comparison of surgical and non-surgical methods of treating palatally impacted canines. II Aesthetic outcomes, 8
Overbite

Changes in interdental papillae heights following alignment of anterior teeth, 16


Orthodontic brackets

Effect of Topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study, 46


Orthodontic treatment

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Overjet

Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1
Reliability of retainers

The reliability of bonded lingual retainers, 24


Satisfaction

The impact of orthodontic treatment on normative need. A case-control study in Peru, 50 Lower intercanine width and gingival margin changes. A retrospective study, 41 Sella turcica bridges in orthodontic and orthognathic surgery patients. A retrospective cephalometric study, 30 Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1 Comparison of surgical and non-surgical methods of treating palatally impacted canines. II Aesthetic outcomes, 8
Orthodontic treatment need

Treatment of skeletal 2 malocclusion using bone-plate anchorage. A case report, 65 The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Palatally impacted canines

Comparison of surgical and non-surgical methods of treating palatally impacted canines. II Aesthetic outcomes, 8
Sella turcica bridge

Sella turcica bridges in orthodontic and orthognathic surgery patients. A retrospective cephalometric study, 30
Sliding mechanics

Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1
Palatal bone thickness

Space closure using the Hycon device. A case report, 72


Space closure

Assessment of palatal bone thickness in adults with cone beam computerised tomography, 109
Periodontal disease

Space closure using the Hycon device. A case report, 72


Spacing

The impact of orthodontic treatment on normative need. A case-control study in Peru, 50


Orthognathic surgery

Treatment of a Class I deep bite malocclusion in a periodontally compromised adult, 130


Periodontal health

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Static friction

Sella turcica bridges in orthodontic and orthognathic surgery patients. A retrospective cephalometric study, 30
Open bite

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Periodontal responses

Static frictional resistances of polycrystalline ceramic brackets with conventional slots, glazed slots and metal slot inserts, 36
Surgical exposure

The relationship between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature, 121
Orthodontics

Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1
Periodontal treatment

Comparison of surgical and non-surgical methods of treating palatally impacted canines. I Periodontal and pulpal outcomes, 1
Temporary anchorage device

Fracture characteristics of fibre reinforced composite bars used to provide rigid orthodontic dental segments, 104

Treatment of a Class I deep bite malocclusion in a periodontally compromised adult, 130

Use of miniscrews as temporary anchorage devices in orthodontic practice. II Case reports, 137

187

Australian Orthodontic Journal Volume 23 No. 2 November 2007

187

INDEX

3D-CT

Typodont study

Three-dimensional computer craniofacial tomography (3D-CT): potential uses and limitations, 55


Three-dimensional computed tomography

Accuracy of bracket placement by orthodontists and inexperienced dental students, 96


Upper retainers

Three-dimensional computer craniofacial tomography (3D-CT): potential uses and limitations, 55


Topacal C-5

The reliability of bonded lingual retainers, 24


Young adults

Effect of Topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study, 46

The impact of orthodontic treatment on normative need. A case-control study in Peru, 50

188

Australian Orthodontic Journal Volume 23 No. 2 November 2007

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